ACKNOWLEDGEMENT

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

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

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

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

GENERAL OBJECTIVES

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

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

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

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

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

Acquire necessary data of our client which are relevant to our case study; Trace the patients family lineage and present remarkable familial disease; Trace the health history of the client and the family by collecting information both from the past and present illnesses;

Evaluate the clients development guided by Erik Erikson, Robert Havighurst and Jean Piagets Theory;

Define the complete diagnosis of our client guided by three different sources; Perform cephalocaudal assessment to the client thoroughly; Discuss the systems involved in the development of the disease in the human anatomy and physiology;

Present the etiology and symptomatology of the disease process with each of its rationales and identify which are present on the clients case;
Sends thesignal to the medulla oblongata to presentcough
Crackles and Wheezes

Trace the pathophysiology of the disease as experienced by our client and it through a schematic diagram;

Present and analyze the doctors order in chronological manner; Explain and interpret both actual and possible diagnostic studies including indication, result, and their implications;

The mucosal lining nerves detects the excessive the secretions

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

large quantities Chemical mediators irritate the goblet cells of the bronchial nursing lining Stimulates Diapedesis and positive Virginia chemotaxis of Leukocytes Inflammation of the Parenchyma
Fever

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

Identify different nursing theories made by

Florence Nightingale,

Henderson and Lydia Hall and relate it on the patients conditions;

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

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

Obstruction of the airway

Cilia fail to sweep the mucous to the because of thickness Histamine causes vasodilation Prostaglandin and Leukotrienes causes blood vessels to be more permeable Damage of the cells release Histamine, Prostaglandins and Leukotrienes Blood vessels leak. Damage on the blood vessels is scant Predisposing factors: Age- elderly adults (age above 70)

Present a discharge plan for the patient Present and justify the prognosis of our patient

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

Accomplish our case presentation.

Precipitating factors: Smoking Alcoholism

6 Hematemesis and

GI bleeding If treated: MGT: Transplantatio n Paracentesis Medications plasmaphorese s If not treated Progressive liver destruction, systemic counsel Hepatic encephalopath y Toxic substance production Mental retardation Hepatic coma

PATIENTS DATA

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

DEATH
- Destruction of cell membranes causes red blood cells to burst Nursing Resp: -Give supplements containing Vit.E

CLINICAL DATA Date of admission: February 6, 2010 Time of admission: 04:09PM Mode of admission: Ambulatory Chief complaint: malaise, loss of appetite, nausea, and black tarry stool

Nursing Resp: 7 -Give Vit.D fortified milk

-Give supplementati on

Ward: MED - CP Admitting physician: Dr. Emerson R. Taghoy Vital signs upon admission: Temp: 36.6 C BP: 90/60 mmHG PR: 65 bpm RR: 28 cpm Final diagnosis: CAP MR Ascites 2 Liver Cirrhosis Source: Significant others and patient's chart
Varices and hemorrhoids May rupture and bleed Vitamin D Decrease absorption of calcium and Phosphorus from the GI tract Vitamin E Decrease against oxidative damage caused by free radicals Nursing Resp:

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

-prevent injury -decrease risk for infection

GENOGRAM
Lola-har

Lolo-har

Development of tissues, and resistance to infections

Body malaise Decreased source of MAMA-HARenergy Auntie Decreased glucose in the body Decreased vitamin K

Grandmade r

Titahar

Manong

PAPA-HAR

Tito

Kol

Gwaping

Boylet

Gwafa

Keks

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

Cutieq

LEGEND: MALE FEMALE

Nursing Resp: Nursing Resp: -Assess pain scale -Monitor VS -Administer analgesic as ordered 9

DECEASED TB HYPERTENSION
q
LIVER CIRRHOSIS

Absence of bilirubin in the feces Bile unable to reach Gi tract Clay colored stool ASCITES Third spacing occurs Mr.Cuties wife and daughter since he was not able to verbalize due to his condition.

FAMILY BACKGROUND AND HEALTH HISTORY Family History

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

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

JAUNDICE

Speeds up destruction of RBCs

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

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

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

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

Blood regurgitation diagnosed: on August of the year 2009. In reference to the diagnosis that was given by to the spleen , tract the physician, maintenance medication was given to the three of them howeverGI they Prominent forgot since they only used the said the medication for about two weeks. Finances were a distended blood vessels factor since they were not able to comply the medication prescribed by the physician. in the stomach Bleeding The family does not seek medical advice until the condition they have worsens as tendencies

stated by Cuties wife. All of them had experienced fever, flu, cough, colds, stomach

Shunting of blood from pains, etc. but again they dont seek medical attention until condition becomes worse. portal vessels to vessels with lower pressure Decrease in osmotic pressure 10 KIDNEYS

Signal for aldosterone release Na+ absorption/ H2O retention excretion

Lifestyle

K+ As verbalized by the patients wife, the patient at his young age was a typical

adolescent who goes with friends and often explores things around. As stated, the patient was curious at all things and because of that he was inclined to a number of vices which

EDEMA

No free blood passage may actually have affected his health status. He was smoking badly as he was able to

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

Backflow of bile the blood

long neck of Tanduay on his own. At times, he goes beyond 1 long neck and even drinks Bile goes to half a gallon of Tuba when he is not yet drunk. As stated by his wife, his husband does stream
collateral in the GI system Accumulation of ammonia convert ammonia to urea Decreased

not stop drinking unless he becomes drunk. As the normal things go as stated by his Formation of wife, the patient and his drinking colleagues use same glass whenever they drink. All of vessels blood these had been the lifestyle of the client since then.

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

drink and smoke whenever he has time. He often sleeps at 10:00pm and wakes Unable up at to 5:00am then takes his breakfast and goes to his work. He takes his break from 11:30am up to 12:30pm and thus eats his lunch. He goes to work and ends at 5:00pm. What he

normally does is clean the plantation and get rid of unwanted growth of grasses allglucogenesis over the place that may alter the good growth of the trees that were present. Whenever he has Decrease in spare time such as weekends which is his rest day from work, he stays at home, watches production TV or talks with his children or goes to his neighbor and drinks. He had such routine Obstruction until of last year, 2009, when he finally had stopped doing his usual things when he was circulation diagnosed of having hypertension. He drinks rarely and smokes only about 2-4 sticks aPortal day compared before when he was not yet diagnosed with hypertension.
hypertension Liver Decreased RBC 11 Body malaise, pallor portal albumin

Change to Fowlers position, assess CRT

Decreased erythropoietin

Diet

Hepatic fibrosis

The patients wife was able to notice that his husband was fond of eating fatty Impaired foods such as taba sa baboy. Whenever they have this kind of viand, she reported that function
hepatocyte

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

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

dong ana man gyud na sa pobre. Moreover, drinking coffee every morning has always been the routine of his husband, still reported by his wife.
Age (45-75 yrs old) Race

History of past illness

Race: Asian

Other than ordinary fever, cough, and flu, which they treat only through over-thePathophysiology counter drugs and no consultations, the patient didnt have any serious illness. This was of Liver Cirrhosis the case, however, until he reached the old age when different signs and symptoms started to manifest, increased blood pressure arise. He then sought medical advice since there were other manifestations of hypertension such as dizziness, nausea and pain on his
Precipitating factors: alcoholism Diet

nape. Then he found out that he has hypertension as diagnosed. Only through daily BP Chronic taking at Santo Tomas Clinic, a clinic just around the area, did they found out about this

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

medications that were prescribed to him by the said clinic.

sMOK Portal obstruction Grandfader 12

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

13

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

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DEVELOPMENTAL DATA

Erik Eriksons Psychosocial Theory of Development Theory Erik Erikson, in his Psychosocial Theory of development, believed that personality develops in a series of stages. Erikson's theory proposes that life is a sequence of developmental stages or levels of achievement. He described eight stages of development and in each stage signals a task that must be accomplished. Our progress through each stage is in part determined by our success, or lack of success, in all the previous stages. Erikson also believed that the more success an individual has at each developmental stage, Stage Integrity versus Despair (65 years old and above) This stage focuses on reflecting back on life. Integrity means feeling at peace with oneself and the world. No regrets or recriminations. Despair and/or 'Disgust' represent the opposite disposition: feelings of wasted opportunities, regrets, wishing to be able to turn back the clock and have a second chance. Those who are unsuccessful during this phase will feel that their life has been wasted and will Result and Justification The patient has fully achieved integrity. According to his wife, Cutie is already contented with his life. His wife verbalized "Kamao ka dong, miskan ana ra na akong bana, wala gyud na siya nagmahay ug tamantaman sa mga nangahitabo sa among kinabuhi. Simple ra nga panginabuhi ra ang among panginabuhi pero wala gyud na siya nag dahum na mudato. Kontento na siya sa amo.

experience many regrets. The Okay na sa iya kay individual will be left with feelings of bitterness and napadako niya ug maayo among mga anak,

15

the healthier the personality of an individual is.

despair. Those who feel proud of their accomplishments will feel a sense of integrity. Successfully completing this phase means looking back with few regrets and a general feeling of satisfaction. These individuals will attain wisdom, even when confronting death.

makahikahos mi sa pang adlaw-adlaw." Despite of it, the patient was not able to send his three children in college. Moreover, the patient has been alcoholic for almost 60 years and been smoking since his teenage years. These habits are wasted opportunity and Mr. cutie has not attained the wisdom since he was not able to decipher that his vices would affect his health in the long run.

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Robert Havighursts Developmental Task Theory Theory Havighurst believes that in every developmental stage, certain tasks are needed to be accomplished for ones progression. In his theory, he proposes that growth and development is occurring during six stages in life, each associated with six to ten tasks to be learned. Havighurst identified Six Major Stages in human life covering birth to old age. Infancy & early childhood (Birth till 6 years old), Middle childhood (6-13 years old), Adolescence (1318 years old), Early Adulthood (19-30 years old), Middle Age (3060years old), and Later 4. Establishing an explicit affiliation with ones age group. 5. Meeting civic and social 1. Adjusting to decreasing physical strength and health. 2. Adjusting to retirement and reduced income. 3. Adjusting to death of a spouse. Stage Later Maturity (60 and above) This stage in a persons life is concerned with the achievement of the following tasks: Result and Justification The patient has not fully achieved this stage since some tasks are not accomplished. He has his circle of friends whose age is almost same with his. They drink and play cards together. But according to his wife, he is not still used to his deteriorating strength. We always wanted to work or at least to keep his self busy, same as the thing he has been doing when he was still younger, but his strength is limiting him already. Therefore, he was not able to adjust from his physical limitation due to aging.

17

maturity (60 years old and over). From there, Havighurst recognized that each human has three sources for developmental tasks. They are: * Tasks that arise from physical maturation: Learning to walk, talk, control of bowel and urine, behaving in an acceptable manner to opposite sex, adjusting to menopause. * Tasks that arise from personal values: Choosing an occupation, figuring out ones philosophical outlook. * Tasks that have their source in the pressures of society: Learning to read, learning to be responsible citizen. A developmental

responsibilities. 6. Establishing satisfactory physical living arrangements.

18

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

JEAN PIAGETS THEORY OF COGNITIVE DEVELOPMENT Theory Stage Result and Justification
19

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

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

The patient did not achieve this cognitive stage. The patient is a chronic alcohol drinker and a smoker. From that alone, he must have thought that this will have a bad effect on his health. He was not able to reason out logically and did not able to see the bigger picture that can be brought about by his vices that these will result to illness.

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DEFINITION OF COMPLETE DIAGNOSIS CAP MR Ascites 2 Liver Cirrhosis

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

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

21

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

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

Patient Characteristics Demographics Male Female

Points

Age (years) Age (years) 10

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Patient Characteristics Nursing home resident Comorbid illness Neoplastic disease Liver disease Congestive heart failure Cerebrovascular disease Renal disease Physical examination findings Altered mental status Respiratory rate >30 breaths per minute Systolic blood pressure < 90 mm Hg Temperature < 35C (95F) or >40C (104F) Pulse rate >125 beats per minute Laboratory and radiographic findings Arterial pH < 7.35 Blood urea nitrogen >64 mg per dL (22.85 mmol per L) Sodium < 130 mEq per L (130 mmol per L) Glucose >250 mg per dL (13.87 mmol per L) Hematocrit < 30 percent Partial pressure of arterial oxygen < 60 mm Hg or oxygen percent saturation < 90 percent Pleural effusion Total points: Mortality % (No. of Point total No predictors 70 71 to 90 91 to 130 >130 Risk Low Low Low Moderate High Risk class patients) I II III IV V 0.1 (3,034) 0.6 (5,778) 2.8 (6,790) 8.2 (13,104) 29.2 (9,333)

Points + 10 + 30 + 20 + 10 + 10 + 10 + 20 + 20 + 20 + 15 + 10 + 30 + 20 + 20 + 10 + 10 + 10 + 10 _______ Recommended site of care Outpatient Outpatient Inpatient (briefly) Inpatient Inpatient

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

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

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

Ascites

24

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

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

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

25

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

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

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

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

Source: Blackwells Dictionary of Nursing 5th Edition, 2004

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27

PHYSICAL ASSESSMENT

Date and Time Performed: February 11, 2010 at 5:00 pm Personal Data Cutie is a male patient admitted to the Med CP of Davao Medical Center. He is 72 years old and was born on May 23, 1937. He was born in IGACOS, Davao City and is currently living at Buhangin, Davao City. He is Filipino and a Christian (Roman Catholic) in religion. He is married. The reason for his admission is malaise, loss of appetite, nausea, and black stools experienced on the 6th of February, 2010. Health History The patient claimed that he never had any past illnesses that lead him to an admission to a hospital. It was just a number of feverish experiences, cough, colds and flu which he had. It was stated by his wife upon our interview that he was diagnosed with hypertension a year ago and had maintenance medications. And just a month ago, he then had chest pain, dizziness, nausea, and body malaise. General Survey Received lying on bed unconscious as evidenced by the patient not responding to verbal and pain stimuli. Patient had an IVF of D5NaCl at 80cc/hr infusing well at left metacarpal vein; with endotracheal tube with O2 at 5-7 L/min connected to a bag valve; with Foley catheter connected to a Urobag draining 100 cc of dark yellow colored urine. He was untidy as the patient was with dirty feet and untrimmed and dirty nails.
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Vital Signs: BP- 110/70mmhg PR- 96bpm Skin The patient had jaundice with uniform skin color all throughout the body except under his axillae, which is darker. His skin folds and axillae were moist. Skin temperature was uniform in all extremities when touched. Senile skin was noted. Hair Upon inspection, hair was short and white in color. His hair was thin and evenly distributed as evidenced by the absence of areas of alopecia along the scalp. No infection or infestations were noted upon inspection and palpation of the patients hairline and scalp. Dandruff was noted on patients scalp however there were no lesions, lumps, or masses upon palpation. Nails Clubbing of nails was noted on patient. Upon palpation, nail base was firm and fingernails had a rough texture. Epidermis surrounding the nails was intact and no lesions were noted. Nails were long, dirty and untrimmed. Toenail surface was slightly curved and rough. Temperature- 38.3 RR- 24

29

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

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

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

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ANATOMY AND PHYSIOLOGY

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

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

Bile production and excretion Excretion of bilirubin, cholesterol, hormones, and drugs Metabolism of fats, proteins, and carbohydrates Enzyme activation

34

Storage of glycogen, vitamins, and minerals Synthesis of plasma proteins, such as albumin and globulin, and clotting factors Blood detoxification and purification

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

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

35

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

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

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

36

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

37

The path is as follows:

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

merge to form >> common hepatic duct >> exits liver and joins >> cystic duct (from gall bladder) >> forming >> common bile duct >> joins with >> pancreatic duct >> forming >> ampulla of Vater >> enters duodenum The anatomy of the biliary tree is a little complicated, but it is important to

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

38

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

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

39

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

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

Hepatic Portal Circulation The veins of the hepatic portal digestive circulation organs, drain spleen, the and

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

41

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

42

ETIOLOGY

43

Basic Etiology Predisposing Factors Male

Present/ Absent

Rationale

Actual

Liver Cirrhosis occurs mostly in men. http://www.cancer.org/docr oot/cri/content/cri_2_2_2x_ what_causes_liver_cancer_ 25.asp

The patient is male.

Ages 45-75

Liver Cirrhosis is most common among people ages 45-75 years old. In Asia and Africa, cirrhosis is also common but more likely to be associated with hepatitis. http://esynopsis.uchc.edu/e Atlas/GI/1210.htm

The patient is 72 years old.

Race: Asian

The patient is an Asian since he was born from Filipino parents, and he was born in IGACOS, Davao City, and currently resides here in Buhangin, Davao City.

Biliary atresia

Infants can be born without bile ducts (biliary atresia) and ultimately develop cirrhosis. The bile ducts carry bile formed in the liver to the intestines, where the bile helps in the digestion of fat. So, when the bile ducts are blocked, bile is trapped in the liver, http://www.medicinenet.co m/cirrhosis/page3.htm

The patient has no record or history of Biliary atresia.

44

Basic Etiology Precipitating Factors Chronic alcoholism

Present/ Absent

Rationale

Actual

Chronic high levels of alcohol consumption injure liver cells. Alcohol seems to injure the liver by blocking the normal metabolism of protein, fats, and carbohydrates. Alcohol can poison all living cells, causing liver cells to become inflamed and die. Thirty percent of individuals who drink daily at least eight to sixteen ounces of hard liquor or the equivalent for fifteen or more years will develop cirrhosis. http://www.emedicinehealth.com/ cirrhosis/page2_em.htm#Cirrhosi s%20Causes

As stated by the patients wife, the patient at his young age was able to drink 1 long neck (750 ml) of Tanduay on his own. At times, he goes beyond 1 long neck and even drinks half a gallon of Tuba when he is not yet drunk. As stated by his wife, his husband does not stop drinking unless he becomes drunk. When he reached his adulthood, he continues to drink and smoke when he finds time to do them.

Chronic viral hepatitis (types B, C, and D).

Condition where hepatitis B or hepatitis C virus infects the liver for years. some patients infected with hepatitis B virus and most patients infected with hepatitis C virus develop chronic hepatitis, which, in turn, causes progressive

The patient had no medical record of acquiring hepatitis B, C, or D.

45

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

46

Smoking

Research reveals that smoking damages the liver. Smoking activates chemical materials within the body. These chemicals also provoke oxidative stress which is linked with lipid peroxidation. When this occurs, the condition fibrosis is developed. Smoking increases the manufacturing of proinflammatory cytokines which is related to liver cell damage. Smoking also contributes the continued succession of chronic alcoholic-hepatitis as well as to the progression of cirrhosis.

The patient smokes 1-2 packs of cigarette a day, and he started smoking when he was a teenager. also drinks Tanduay (750mL) 2-3 times a week since he was a teenager. He only stopped smoking when he was diagnosed with hypertension last 2009.

that are manufactured by smoking At the same time, he

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

47

Malnutrition, especially high fat intake

Fat builds up in the liver and eventually causes cirrhosis. Fat (triglycerides) accumulates throughout the hepatocytes for the following reasons:

There is no scientific basis that the patient has an increase fat in the blood or increased level of cholesterol in the blood (LDL-bad cholesterol)

Export of fat from the liver is decreased because hepatic fatty acid oxidation and lipoprotein production decrease.

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

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

48

SYMPTOMATOLOGY

SYMPTOMS

Present/ absent

Rationale

Actual

Anorexia

Increased brain tryptophan (TRP) availability for serotonin synthesis play a role in the pathogenesis of anorexia. Since in chronic liver failure, increased plasma and cerebrospinal fluid TRP concentrations are characteristically reported, that also in liver cirrhosis, increased brain TRP availability constitute the pathogenic mechanism of anorexia.

This is present with the patient, since this is one of the reasons he consulted the emergency room. The wife stated that the patient had no appetite to eat

http://www3.interscience.wiley.com/j ournal/49716/abstract? CRETRV=1&SRETRY=0 Nausea and vomiting The malabsorption of fats may lead to deficit of fatsoluble vitamins, hemorrhoids, intolerance to fatty foods, nausea and vomiting attacks, and abdominal bloating. Since the liver has already decreased in function, its function to produce bile which emulsifies fats is also decreased, thus these symptoms persists. Two weeks prior to admission, the patient started feeling nauseous, and four days prior to admission, he had prandial vomiting which is one of the reasons he

49

www.enwikipedia.org/wiki/Liver_dis ease#Symptoms_of_a_diseased_liver

sought consultation at the emergency room.

Body malaise

This is due to the decreased in liver function of the liver because of the hepatic fibrosis. Therefore, the patient has also decreased erythropoietin which then results to the decrease of red blood cells circulating in the blood, and there will be decreased hemoglobin. All of this in return will cause the patient to have body malaise.

The patient experienced body malaise, and was one of his chief complaint that resulted to his admission at DMC.

Bleeding tendencies

Bleeding tendencies such as nosebleeds, easy bruising, and bleeding gums may result from thrombocytopenia secondary to splenomegaly, decreased vitamin K absorption and decreased production of coagulation factors and regurgitation of blood to the spleen and gastrointestinal tract.

The patient had bleeding as evidenced by him having black stools, which is also known as melena, indicative of bleeding in the upper gastrointestinal tract.

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

Portal

Portal hypertension occurs because of The patient has

50

hypertension

the obstruction of portal circulation brought about by the portal obstruction caused by the hepatic scarring. http://www.emedicinehealth.com/cirr hosis/page2_em.htm#Cirrhosis %20Causes

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

Ascites

This

happened

because

of

the The patient has

decrease of albumin in the blood ascites as plasma. Albumin is responsible for evidenced by his maintaining the oncotic pressure in distended the blood volume. A decrease in abdominal cavity. albumin will mean a decrease in oncotic pressure, which will result to a more permeable membrane which results to fluid leaking through the vasculature cavity. Suddarth, Doris Smith. The Lippincott Manual of Nursing Practice. 5th edition. 1991. Pages 514515. Jaundice Jaundice is the buildup of bile pigment that is passed by the liver The patient was noted to have
51

into

the

abdominal

into the intestine. Due to the portal obstruction, the bile going to the GI tract will have a backflow to the liver. The bile then goes to the blood stream, and this causes the yellowing of the skin, due to the presence of bi (http://www.healthscout.com/ency/68 /292/main.html)

yellowish skin color on all four extremities including the palms. The patient also had icteric sclera when inspected.

edema on the extremities

Plasma albumin is reduced, leading One week prior to to edema. Suddarth, Doris Smith. The Lippincott Manual of Nursing 515. admission, the wife of the patient noticed the obvious distention of the patients abdomen. Upon physical assessment, the patient was noted to have ascites and edema on all four extremities.

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

Caput medusae

Portal hypertension results from the abnormal blood flow pattern in liver created by cirrhosis. The increased pressure is transmitted to collateral venous channels. Sometimes these venous collaterals are dilated. Caput

The patient was noted to have large, dilated, and distended veins on the abdomen area when

52

medusa consists of dilated veins seen on the abdomen of a patient with cirrhosis of the liver.

inspected

Coma

This is a progressive symptom, The patient is on a secondary to the loss of ammonia to comatose state. urea brain. Deterioration of mental function from lethargy to coma and eventual death conversion and consequent delivery of toxic ammonia to the

PATHOPHYSIOLOGY

53

PATHOPHYSIOLOGY

54

DOCTORS ORDERS DATE DOCTOR'S ORDER Feb. 6, 2010 Please admit patient Admission in the hospital is required under blue service for optimum medical and nursing care; ADMITTED RATIONALE REMARKS

55

Level II CP Pavillion and to receive medications, undergo tests, and perform procedures which can only be done in the hospital setting. The blue service accommodates patients with gastro, endo and immunologic problems. VSq4 and record please Vital signs are taken to provide baseline data and to watch-out for any unusualities. Start venoclysis with Helps expand intravascular volume, PNSS 1L @ 120cc/hr corrects an underlying imbalance in fluids and electrolytes and compensates the loss in the body. Moreover, it serves as a route for medication. Labs: CBC PC CBC (complete blood count and DONE TAKEN AND RECORDED STARTED

platelet count) is a basic screening test WITH and is one of the most frequently ordered laboratory procedures. The findings in the CBC PC give valuable diagnostic information about the hematologic and other body systems, prognosis, response to treatment and recovery. RESULTS

CXR-PA

A chest radiograph is used to diagnose DONE BUT

56

conditions affecting the chest, its contents, and nearby structures. Chest radiographs are among the most common films taken, being diagnostic of many conditions. A chest x-ray may be ordered when a person's symptoms include a persistent cough, coughing up blood, chest pain, a chest injury, or difficulty in breathing. ECG ECG is a non-invasive test used to assess the heart function. It is a graphic produced by an electrocardiograph, which records the electrical activity of the heart over time. B1 B2 Elevation of serum bilirubin levels is related to hemolysis of RBCs and subsequent re-absorption of unconjugated bilirubin from the small intestines. The condition may be benign or may place the patient at risk for multiple complications/untoward effects.

NO IMPRESSIO N MADE

NOT DONE

DONE WITH RESULTS

57

BUN

The BUN test is primarily used, along DONE with the creatinine test, to evaluate kidney function in a wide range of circumstances, to help diagnose kidney disease, and to monitor patients with acute or chronic kidney dysfunction or failure. Increased BUN levels suggest impaired kidney function. This may be due to acute or chronic kidney, damage, or failure. WITH RESULTS

S. Na, S. K

Serum sodium and serum potassium levels are checked to determine fluid and electrolyte balance.

NOT DONE

Crea

A disorder in the kidney function reduces excretion of creatinine, resulting in increased blood creatinine levels. This test diagnoses impaired renal functions.

NOT DONE

SGPT and SGOT

Elevations of SGPT, an enzyme found DONE within the liver cells, indicate that the WITH liver cells are either leaky (internal contents are entering the blood) or damaged. RESULTS

58

Meds: Furosemide 40 mg tab OD Spironolactone 25mg tab OD

Inhibits reabsorption of sodium and chloride at proximal and distal tubule and in the loop of Henle Spironolactone inhibits the action of aldosterone thereby causing the kidneys to excrete salt and fluid in the urine while retaining potassium.

GIVEN

GIVEN

Essentiale Forte CAP BID

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

GIVEN

I&O q shift

Intake & output monitoring is done to assess the fluid retention status of the patient and to prevent cardiac overload.

RECORDED

Watch out for any unsualities

To ensure that immediate nursing interventions can be rendered in cases of deviances from the normal health status so complications can be prevented

WATCHED OUT

Refer accordingly

Referral is done to correct unusualities as soon as possible and to inform the

REFERRED

59

attending physician of the patient's condition. February Labs: CBC PC, 7, 2010 @ 4:00 AM These tests were not yet done and so NOT DONE

ECG, B1 B2, S. Na, the doctor ordered again and made K, Crea, SGPT, SGOT Follow up chest Xray reading This is to inform the patient or FOLLOWED requests for these tests for analysis.

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

Additional labs: 1. Transabdominal USD

Transabdominal USD is ordered to for NOT DONE visualization of the abdomen which helps in diagnosing the patients condition.

2. Serum albumin

A serum albumin test measures the amount of this protein in the clear liquid portion of the blood. This test can help determine if a patient has liver disease or kidney disease, or if the body is not absorbing enough protein.

DONE WITH RESULTS

3. HBS-Ag

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

60

the virus to others. 4. Anti-HAV IgM This test is used to help diagnose a liver infection due to the hepatitis A virus (HAV). This test may also be used to determine if you have produced antibodies and developed immunity in response to a hepatitis A vaccine or a previous hepatitis A infection. 6. Anti-HCV To determine if you have contracted the hepatitis C virus (HCV) and to monitor treatment of the infection 7. PT/PTT Since the Prothrombin time (PT) evaluates the ability of blood to clot properly, it can be used to help diagnose bleeding. When used in this instance, it is often used in conjunction with the PTT to evaluate the function of all coagulation factors. Occasionally, the test may be used to screen patients for any previously undetected bleeding problems prior to surgical procedures. NOT DONE NOT DONE NOT DONE

61

Furosemide 40mg IVTT now, then

Inhibits reabsorption of sodium and chloride at proximal and distal tubule

GIVEN

Furosemide 40mg 1 and in the loop of Henle tab BID Spironolactone 100mg BID Spironolactone inhibits the action of aldosterone thereby causing the kidneys to excrete salt and fluid in the urine while retaining potassium. Essentiale Forte 1 cap TID Increase functional status of the liver, improvement in the lipids metabolism caused by accelerated synthesis of lipoproteins in the liver, activation of the phospholipid-depending ferments, increased synthesis of glycogen in the liver, decreased the fatty infiltration of the hepatocyte Lactulose 30cc @ bedtime Produces osmotic effect in colon. Resulting distention promotes peristalsis. Decrease blood ammonia build- up causes hepatic encephalopathy, probably ass result of bacterial degradation which lowers pH of colon contents. Ceftriaxone 1gm This antimicrobial agent inhibits GIVEN GIVEN GIVEN GIVEN

62

IVTTq12, ANST

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

Please monitor I&0 q shift and record

Intake & output monitoring is done to assess the fluid retention status of the patient and to prevent cardiac overload.

MONITORE D

Refer if UO < 30 cc/hr

A decrease in urine output may indicate REFERRED a serious, even life-threatening condition. It may be caused by dehydration du, diarrhea, lack of adequate fluid intake or total urinary tract obstruction.

CBG q6 (6AM11AM- 6PM 11PM)

The capillary blood glucose test is ordered to measure the amount of glucose in the blood right at the time of sample collection. It is used to

NOT DONE

63

detect both hyperglycemia and hypoglycemia , to help diagnose diabetes, and to monitor glucose levels. Refer if CBG 180mg/dL, < 80mg/dL High levels of glucose most frequently REFERRED indicate diabetes, but many other diseases and conditions can also cause elevated glucose such as chronic renal failure and hyperthyroidism. Low blood glucose levels are seen in patients with drinking alcohol and extensive liver disease. Refer Referral is done to correct unusualities as soon as possible and to inform the attending physician of the patient's condition. February Please do gastric 7, 2010 @ 8:10 AM lavage now until water is clear Please insert FBC F16 and attach to urobag To monitor the intake and output of the INSERTED patient. This may also avoid bladder distention. Gastric lavage is done to address gastrointestinal bleeding. DONE REFERRED

64

Strict I&O monitoring and record please NPO Temporarily

Intake & output monitoring is done to assess the fluid retention status of the

MONITORE D AND

patient and to prevent cardiac overload. RECORDED For better visualization of the abdomen DONE during the ultrasound

Shift IVF to D5NSS D5NSS restores sodium chloride deficit SHIFTED 1L @ 80cc/hr For USD of the whole abdomen, KUB, Pancreas and extra cellular fluid volume. Abdominal ultrasound is an imaging procedure used to examine the presence of abnormalities in the structure of the organs intraabdominally. Continue other meds All medications previously ordered by attending physician should be continued to hasten patient's recovery. Please attach all labs For monitoring and analysis of the requested patients condition through the results of the tests done Feb. 8, 2010 @ Start omeprazole 40mg IVTTq12, 1st Suppress gastric acid secretion by inhibiting the partial cell H+/K+ ATP pump STARTED ATTACHED CONTINUE D NOT DONE

6:20 AM done once available *coffeeground output / NGT

65

Feb. 9, 2010 @ 11:00 AM

Repeat CBC,

These tests were not yet done and so

NOT DONE

protime, USD of the the doctor ordered again and made liver, Pancreas, serum albumin, BUN Lactulose 30cc TID, Produces osmotic effect in colon. to make 4-5 bowl mvt/day Resulting distention promotes peristalsis. Decrease blood ammonia build- up the causes hepatic encephalopathy, probably ass result of bacterial degradation which lowers pH of colon contents. Furosemide 40 mg IVTT, OD Inhibits reabsorption of sodium and chloride at proximal and distal tubule and in the loop of Henle Omeprazole 40mg IVTT q12 Suppress gastric acid secretion by inhibiting the partial cell H+/K+ ATP pump Vit. K 1 amp IVTT OD Essential Forte 1 cap Increase functional status of the liver, TID improvement in the lipids metabolism caused by accelerated synthesis of lipoproteins in the liver, activation of the phospholipid-depending ferments, GIVEN It is given to prevent bleeding. GIVEN GIVEN GIVEN GIVEN requests for these tests for analysis.

66

increased synthesis of glycogen in the liver, decreased the fatty infiltration of the hepatocytes Metronidazole 500mg 1 TAB q6 Disrupts DNA and protein synthesis susceptible organisms. Therapeutic effects: Bactericidal, trichomonacidal or amebicidal action. Spectrum: Most notable for avtivity against anaerobic bacteria including: Bacteroides, clostridium. In addition is active against: Trichomonas vaginalis, entamoeba histolytica, giardia lamdia, H. pylori and clostridium difficile. Hold all PO Meds Holding all PO meds is done as preparation for the gastric lavage. Giving medications would just be drawn out of the patients stomach during the procedure. Pls. do gastric lavage Gastric lavage is done to address until gastric aspirate gastrointestinal bleeding. goes out clear NPO temporarily For better visualization of the abdomen DONE during the ultrasound CBG Monitoring q6 The capillary blood glucose test is ordered to measure the amount of NOT MONITORE DONE DONE GIVEN

67

glucose in the blood right at the time of sample collection. It is used to detect both hyperglycemia and hypoglycemia , to help diagnose diabetes, and to monitor glucose levels. Refer for persistent To notify the physician regarding the in sensorium changes of the patients health status and to prevent further complications Feb. 9, Restrain if necessary Patient may be restless or uncomfortable with the equipment attached to him needing a restraint to keep them in place and prevent dislodging causing harm. Feb. 10, Repeat CBC Plt Ct, 2010 @ 1PM Protime with INR, Serum Na, K, Crea, ABG These tests were not yet done and so the doctor ordered again and made requests for these tests for analysis. Blood gases are a measurement of how much oxygen and carbon dioxide is in your blood. It also determines the acidity (pH) of your blood. The test is used to evaluate respiratory diseases and conditions that affect the lungs. It helps determine the effectiveness of

REFERRED

RESTRAINE D

2010 @ (per watchers 12:05 PM request)

NOT DONE

DONE

68

oxygen therapy. The test also provides information about the body's acid/base balance, which can reveal important clues about lung and kidney function and the body's general metabolic state. Please facilitate transport on USD test today To conduct ultrasound testing to the patient which may be helpful in determining other problems in the patients health status NPO temporarily For better visualization of the abdomen DONE during the ultrasound Give tranexamic Inhibits activation of plasminogen, GIVEN FACILITAT ED

acid 100mg IVTT q8 thereby preventing the conversion of plasminogen to plasmin Give Vit. K 1 amp now, OD For gastric lavage today without fail This is to ensure that the patient would DONE undergo the gastric lavage as it is needed by the patient immediately on the same day as per doctors request NPO except meds Restrictions for any intake per orem except the medications is given for better visualization of the abdomen during the ultrasound and for patients DONE It is given to prevent bleeding. GIVEN

69

recovery through the therapeutic effects of medicine. Start albumin 25% 50 cc q12 To compensate for the decreased albumin levels which is responsible for maintaining osmotic pressure inside the blood vessels BP monitoring qh until stable To monitor changes in the blood pressure which is significant in determining the patients status Continue meds All medications previously ordered by attending physician should be continued to hasten patient's recovery. Refer Referral is done to correct unusualities as soon as possible and to inform the attending physician of the patient's condition. Feb, 10, Referred for 2010 sensorium, (E1 V3 M5) GCS 9 CR 90 RR 22 T- 39 Glasgow Coma Scale or GCS, is neurological scale which aims to give a reliable, objective way of recording the conscious state of a person, for initial as well as subsequent assessment. (E1 does not open eyes, V3- Utters inappropriate words, M5 Localizes painful stimuli) Moderate Brain Injury, GCS 9 12 REFERRED REFERRED CONTINUE D MONITORE D STARTED

70

Do ABG now

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

DONE

Do CBG now

The capillary blood glucose test is ordered to measure the amount of glucose in the blood right at the time of sample collection. It is used to detect both hyperglycemia and hypoglycemia , to help diagnose diabetes, and to monitor glucose levels.

NOT DONE

O2 inhalation @ 5-7 O2 inhalation is indicated for patients L/min via face mask that lack oxygen supply and need assistance in maintain the desired

DONE

71

oxygen supply Monitor VS qh and record The patient is for close monitoring and MONITORE needs further assessment to monitor to D address if theres any unusualities Refer Referral is done to correct unusualities as soon as possible and to inform the attending physician of the patient's condition. Feb. 11, Follow-up requested For monitoring and analysis of the 2010 labs patients condition through the results of the tests done For gastric lavage Gastric lavage is done to address gastrointestinal bleeding. Cold water is used to prevent any bleeding in the gastrointestinal tract. IVF of PNSS 1L @ 80cc/hr Helps expand intravascular volume, corrects an underlying imbalance in fluids and electrolytes and compensates the loss in the body. Moreover, it serves as a route for medication DONE DONE FOLLOWED -UP REFERRED

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

72

like blood to replace body fluids. It is used as a prime once on blood transfusion. Refer Referral is done to correct unusualities as soon as possible and to inform the attending physician of the patient's condition. Feb. 11, Referred due to dec. Glasgow Coma Scale or GCS, is 2010 (+) active bleeding per orem sensorium GCS5 (E1 neurological scale which aims to give V1 M3) & dyspnea a reliable, objective way of recording the conscious state of a person, for initial as well as subsequent assessment. E1- Does not open eyes, V1 - Makes no sounds, M3 (+) gross hematuri a on FC Intubate pt. now Abnormal flexion to painful stimuli (decorticate response), GCS of 5 Severe Brain Injury The ET tube is inserted into a INTUBATE D REFERRED REFERRED

with ET size 75 level patient's trachea in order to ensure that 21 the airway is not closed off and that air is able to reach the lungs. The endotracheal tube is regarded as the most reliable available method for protecting a patient's airway.It is

73

indicated when the oxygenation with noninvasive methods is inadequate CAB while awaiting This is to provide the patient with mech. vent. Support adequate oxygen supply through continues bag valving until the mechanical ventilation support is available. MV Set-up PO2 = 100% RR 16 TV 500cc Insert NGT French Nasogastric intubation is a medical INSERTED To assist the patient in his breathing pattern since he is not able to support his own required oxygen levels. DONE DONE

16 and open to drain process involving the insertion of a plastic tube (nasogastric tube, NG tube) through the nose, past the throat, and down into the stomach. The main use of a nasogastric tube is for feeding and for administering drugs and other oral agents. NPO Temp For better visualization of the abdomen DONE during the ultrasound Give tranexamic acid 500mg IVTT Inhibits activation of plasminogen, thereby preventing the conversion of plasminogen to plasmin GIVEN

74

Vit. K 1amp IVTT now hold Suction catheter PRN Turn to sides q2

It is given to prevent bleeding.

GIVEN

To remove retained secretion in the catheter to clear obstructed airway Turning the patient to sides prevents the patient from developing decubitus ulcer.

SUCTIONE D DONE

Continue meds

All medications previously ordered by attending physician should be continued to hasten patient's recovery.

CONTINUE D

Refer

Referral is done to correct unusualities as soon as possible and to inform the attending physician of the patient's condition.

REFERRED

Feb. 11, Transfer to CP6 or 9 To provide better care and monitoring 2010 @ 12NN awaiting for ICU vacancy For referral to consultant c/o Dr. Honcoda today To receive 2U PRBC In order to increase the number of red and transfuse once available To secure 6U FFP and transfuse once available For the treatment of deficiencies of coagulation proteins for which specific factor concentrates are unavailable or blood cells in the blood to the patient while awaiting for room vacancy in the ICU For co-management and thorough analysis of the patients condition.

TRANSFER RED

INFORMED

TRANSFUS ED

SECURED

75

undesirable. Give tranexamic acid 500mg IVTT q8, 1 dose now For gastric lavage with cold water Inhibits activation of plasminogen, thereby preventing the conversion of plasminogen to plasmin Gastric lavage is done to address gastrointestinal bleeding. Cold water is used to prevent any bleeding in the gastrointestinal tract. Referral to Dr. Pilapil For HBS-AG, AntiHBC IgM, AntiHCV For USD of the whole ABD For co-management and thorough analysis of the patients condition. These tests were not yet done and so the doctor ordered again and made requests for these tests for analysis. Abdominal ultrasound is an imaging procedure used to examine the presence of abnormalities in the structure of the organs intraabdominally. Pls. facilitate transfer To provide better care to the patient in to IMCU/ICU a setting where he will monitored thoroughly. Feb. 11, Paracetamol 300mg 2010 @ 12:45P IVTT now Inhibits the synthesis of prostaglandins GIVEN that may serve as mediators of pain and fever, primarily in the CNS. FACILITAT ED NOT DONE NOT DONE REFERRED DONE GIVEN

76

Refer

Referral is done to correct unusualities as soon as possible and to inform the

REFFERED

T 38.2

attending physician of the patient's condition.

Feb. 12, Dx: HBS-Ag, Anti2010 @ 11:45 AM Still for mech. vent. Support Follow up crossmatching of blood and transfuse once available For compliance to medication HBC, Anti-HCV

These tests were not yet done and so the doctor ordered again and made requests for these tests for analysis. To provide the patient with adequate amount of oxygen For compatibility testing. Crossmatching is important to detect agglutination of donor RBCs caused by antibodies in patient's serum.

DONE

DONE

FOLLOWED -UP

Continuation of medication ensure INFORMED spontaneous condition treatment of patients to the

and

compliance

medical regimen, revealing the desired outcomes Refer Referral is done to correct unusualities as soon as possible and to inform the attending physician of the patient's condition. REFERRED

77

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

pH

7.510

7.35-7.45

mmHg

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

pC02

21.3

35-45

mmHg

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

PO2

82.0

80-100

mmHg

PO2 level is at normal range.

78

HC03

16.6

22.0-27.0

mmol/L

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

02Sat

97.2%

80-100

02 Saturation is at normal range.

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

79

Nursing Responsibilities when withdrawing blood

o

Verify order and patient identity

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

o

Gather equipment and wear clean gloves

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

80

Hematology

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

81

TEST

RATIONALE

REFERENCE RESULT RANGE

N/H/L CLINICAL SIGNIFICANCE

CBC+PLT Hgb Hemoglobin is the protein molecule in red blood cells that carries oxygen from the lungs to the body's tissues and returns carbon dioxide from the tissues to the lungs. Hemoglobin also plays an important role in maintaining Hct the shape of the red blood cells. Hematocrit is a measure of how much space red blood cells take up in the blood. RBC count RBC count is the number of red blood 4.20-6.10 cells per volume of blood, and is reported in either millions in a microliter or millions in a liter of blood. WBC count Measures the amount of white blood cells. These immune cells form in the bone marrow to help fight infection DIFFERENTIAL COUNT
82

115-175 g/L

104

Low hemoglobin is referred to as anemia which may by the decreased erythropoietin caused by cirrhosis of the liver.

0.36-0.52

0.29

Because of the decrease in the RBC in the blood, hematocrit as well would decrease.

2.94

A decreased number of RBCs results from the decrease erythropoietin production of the liver.

x106 /uL

5.0-10.0 x103 /uL

9.65

WBC is in normal range.

83

TEST

RATIONALE

REFERENCE RESULT RANGE

N/H/L CLINICAL SIGNIFICANCE

CBC+PLT Hgb Hemoglobin is the protein molecule in red blood cells that carries oxygen from the lungs to the body's tissues and returns carbon dioxide from the tissues to the lungs. Hemoglobin also plays an important role in maintaining Hct the shape of the red blood cells. Hematocrit is a measure of how much space red blood cells take up in the blood. RBC count RBC count is the number of red blood 4.20-6.10 cells per volume of blood, and is reported in either millions in a microliter or millions in a liter of blood. WBC count Measures the amount of white blood cells. These immune cells form in the bone marrow to help fight infection DIFFERENTIAL COUNT
84

115-175 g/L

107.0

Low hemoglobin is referred to as anemia which may by the decreased erythropoietin caused by cirrhosis of the liver.

0.36-0.52

0.31

Because of the decrease in the RBC in the blood, hematocrit as well would decrease.

3.08

A decreased number of RBCs results from the decrease erythropoietin production of the liver.

x106 /uL

5.0-10.0 x103 /uL

12.78

High levels indicate presence of bacterial infection.

Date ordered: February 9, 2010

85

Blood Chemistry Blood chemistry is the chemical composition of the blood. The levels of various substances in the blood can provide clues to a patient's condition, ranging from the presence of a liver disorder to a pregnancy. Routine bloodwork to check blood chemistry is often a part of a diagnostic workup, with the blood being analyzed to check for specific elements which could contribute clues to the diagnosis. Doctors rely on information about normal ranges of things like proteins and lipids to read the blood analysis. Date ordered: February 9, 2010 TEST RESULT UNIT NORMAL RANGE TOTAL PROTEIN 59.40 g/L 63 - 82 L Low total protein levels can suggest a liver disorder. In Total protein measurements can reflect nutritional status and may be used to screen for and help diagnose kidney disease, liver disease, and many other conditions patients with liver problems, there is a decrease in total protein levels because of the decrease in production of albumin, a protein which is L/N/H CLINICAL SIGNIFICANCE

86

exclusively produced in the liver. GLOBULIN 40.70 g/L 23 - 35 H An elevation in the level of serum globulin can indicate the Globulins are proteins that include gamma globulins (antibodies) and a variety of enzymes and carrier/transport proteins. They are a diverse group of proteins in the blood, and together represent the second most common proteins in the bloodstream. ALBUMIN 18.70 g/L 35 - 50 L There is a decrease of albumin in the blood plasma because of Albumin is the most abundant protein found in blood plasma, representing 40 to 60% of the total protein. A/G RATIO 0.5 1.5 2.5 L A decrease in Albumin the decrease in its production due to problems in the liver. presence of cirrhosis of the liver and bacterial infection.

87

Globulin Ratio is an indicative The ratio of the concentrations of albumin to globulin in blood serum. of a problem in liver functions.

88

Blood Chemistry Date ordered: February 6, 2010

89

Result SGPT ALT (SGPT) is, by 84.0

Unit U/L

Reference Ranges 30.0-65.0

L/N/H H

Clinical Significance An increase in SGPT level is due to impaired liver function caused by liver cirrhosis. It can be caused by hepatic inflammation (including

contrast, normally found infectious mononucleosis, pancreatitis, alcohol, largely in the liver. This viral hepatitis) is not to say that it is exclusively located in liver but that is where it is most concentrated. It is released into the bloodstream as the result of liver injury. It therefore serves as a fairly specific indicator of liver status. SGOT 182.0 U/L 15.0-37.0 H An increase in SGPT level is due to impaired liver function caused by liver cirrhosis. It can be AST (SGOT) is normally found in a diversity of tissues including liver, heart, muscle, kidney, and brain. It is released caused by hepatic inflammation (including infectious mononucleosis, pancreatitis, alcohol, viral hepatitis)
90

91

DRUG STUDY

Deneric Name

Brand Name Classification

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

(chemical) Sulfonamide derivative Dosage and Route 40 mg tab OD Mechanism of Inhibits reabsorption of sodium and chloride at proximal and distal tubule Action and in the loop of Henle Indication Pulmonary edema, hypertension, third spacing Contraindication Hypersensitivity to sulfonamides, anuria, hypovolemia, infants, lactation and electrolyte depletion Drug Interaction >increased toxicity with lithium, non-depolarizing skeletal muscle relaxant >increased hypotensive action with antihypertensives and nitrates Side/Adverse Effects >increased ototoxicity with aminoglycosides, cisplatin, vancomycin CNS: headache, fatigue, weakness, vertigo CV: orthostatic hypotension, chest pain, ECG changes circulatory collapse EENT: loss of hearing, ear pain, tinnitus and blurred vision ELECT: hypokalemia, hypochloremic alkalosis, hypocalcemia, matabolic alkalosis

GI: nausea, diarrhea, dry mouth, abdominal cramps, gastric irritaions GU: polyuria, renal failure, glycosuria HEMA: thrombocytopenia, agranulocytosis, anemia Nursing INTEG: rash, pruritus, purpura, diaphoresis >assess for drowsiness and restlessness for it may indicate metabolic

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

Generic Name Brand Name Photo

Omeprazole Losec and Prilosec

Classification Gastric acid secretion, proton-pump inhibitor Dosage and Route 40mg IVTTq12 Mechanism of Suppress gastric acid secretion by inhibiting the partial cell H+/K+ Action Indication Contraindication Drug Interaction ATP pump To prevent ulceration in patients under NPO Known hypersensitivity to omeprazole decreased effect: decreased ketoconazole; decreased itriconazole increased toxicity: diazepam increase half-life; increased digoxin, increased phenytoin, increased warfarin Side/Adverse Effects CNS: headache, dizziness Neuromascular & Skeletal: weakness, back pain GI: nausea, diarrhea, vomiting, abdominal pain, constipation, taste perversion Nursing Responsibilities Respiratory: upper respiratory infection, cough Ensure ten rights of medication administration Instruct patient not to chew, crush or open capsule Instruct patient to take before eating, capsule should be swallowed whole

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

Generic Name Brand Name Photo Classification

Spironolactone Aldactone Electrolyte and water balance agent; potassium sparing diuretic

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

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

Mechanism of Action

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

Indication

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

Contraindication Patients

with

anuria,

acute

renal

insufficiency,

significant

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

Generic Name Photo

Ceftriaxone

Brand Name Classification Dosage and Route Mechanism of Action

Rocephin cephalosporin antibiotic 1gm IVTTq12 This antimicrobial agent inhibits bacterial cell wall synthesis by binding to one or more of the penicillin-binding proteins (PBPs) which in turn inhibits the final transpeptidation step of peptidoglycan synthesis in bacterial cell walls, thus inhibiting cell wall biosynthesis. Bacteria eventually lyse due to ongoing activity of cell wall autolytic enzymes (autolysins and murein hydrolases) while cell wall assembly is arrested.

Indication Contraindication Drug Interaction

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

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

Generic Name Photo

metronidazole

Brand Name Classification Dosage and Route Mechanism of Action

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

Indication

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

Contraindication

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

Drug Interaction

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

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

Generic Name

Lactulose

Photo

Brand Name Classification Dosage and Route Mechanism of Action

Contulose Laxative 30cc @ bedtime Produces osmotic effect in colon. Resulting distention promotes peristalsis. Decrease blood ammonia build- up the causes hepatic encephalopathy, probably ass result of bacterial degradation which lowers pH of colon contents. Relieves constipation, decreases ammonia concentration.

Indication

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

Contraindication Drug Interaction

Contraindicated in patients on low- galactose diet Drug-drug. - Should not be used with other laxatives in the treatment of hepatic encephalopathy - Anti- infectives may diminish effectiveness in treatment of hepatic encephalopathy

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

Generic Name Photo

Essentiale Forte

Brand Name Classification Dosage and Route Mechanism of Action

Essential Forte Cholagogues, Cholelitholytics & Hepatic Protectors 1 cap TID Increase functional status of the liver, improvement in the lipids metabolism caused by accelerated synthesis of lipoproteins in the liver, activation of the phospholipid-depending ferments, increased synthesis of glycogen in the liver, decreased the fatty infiltration of the hepatocytes

Indication

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

Contraindication

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

Drug Interaction

Not indicated

Side/Adverse Effects In very rare cases it can cause :abdominal pain, nausea, diarrhea and allergic reaction(skin rash). Nursing Responsibilities 1. Instruct patient on proper use of the drug

Generic Name Photo

Phytonadione

Brand Name Classification Dosage and Route Mechanism of Action

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

Indication

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

Prophylaxis and therapy of hemorrhagic disease of the newborn;

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

other drug-induced hypoprothrombinemia.

Contraindication Drug Interaction

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

Generic name Photo

paracetamol

Brand name Classification Ordered Dosage and Frequency Mode of Action

Aeknin Therapeutic: antipyretics, non-opiod analgesics 300mg IVTT now

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

Indication Contraindication

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

Drug Interactions

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

Adverse Reactions/ Side Effects

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

Generic name Photo

Tranexemic acid

Brand name Classification Ordered Dosage and Frequency Mode of Action

Cyclokapron Hemostatic agent, antifibronolytic agent 100mg IVTT q8

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

Indication Contraindication Drug Interactions

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

Adverse Reactions/ Side Effects

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

Nursing Responsibilities

i.

observe the 10 rights of medication administration of medication

ii. iii. iv. as directed

check for hypersensitivity to drug observe for bleeding instruct patient ot take tranexamic acid

NURSING THEORIES

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

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

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

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

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

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

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

NURSING CARE PLANS Date / Time February 11, 2010 at 4pm Cues Needs Nursing Diagnosis Objective of Care At the end of 7 hours span of care, the patient will have effective airway as evidenced by R: Pneumonia, which is an acute infection of the lungs, causes inflammation in lung tissues which leads to damage on mucous and alveolar membranes. This damage results in secretion of exudates and mucous as the absence of crackles. Nursing Intervention Evaluation

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

A C T I V I T Y E X E

Ineffective airway clearance related to accumulation of secretions secondary to Community Acquired Pneumonia

1. Provide suctioning. R: to clear airway from accumulated secretions. 2. Elevate head of bed. R: Gravity decreases pressure on the diaphragm 3. Turn patient to sides every 2 hours R: repositiong enhances drainage and promotes ventilation to different lung segments. 4. Assist in providing respiratory support through ambu bagging. R: mechanical ventilation maintains adequate airways and improve respiratory functions.

February 11, 2010; 11pm GOAL UNMET After rendering nursing interventions within the 7hours span of care, the patient has still ineffective airway clearance as evidenced by presence of crackles on lung field.

R C I S E P A T T E R N

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

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

Williams, L.S & Hoppers, P.D. (2007). Understanding medical-surgical nursing,3rd ed. Philadelphia: F.A. Davis Company.

still present. 7. Provide oxygen with appropriate humidifier, as ordered. R: to facilitate oxygenation and liquefy secretion for easy suctioning. 8. Monitor oxygen saturation. R: to rule out presence of gas exchange impairement. 9. Carry out diagnostic orders made by the physician such as ABG or AFB and secure result. R: to determine the degree of respiratory impairment such as

presence of hypoxemia.

Date F E B R U A R Y 11, 2010 @ 5:00 PM

Cues Objective cues: Melena

Needs N U T R I T I O N A L M E T A B O L

Nursing. Diagnosis Bleeding related to altered clotting mechanism: decreased prothrombin and thrombin production secondary to liver cirrhosis One of the functions of liver is the production of prothrombin and thrombin which are substances needed to help blood coagulate. In patients with liver cirrhosis, they are at higher instances of bleeding because of the decreased coagulation factors.

Objective Within the 8 hours span of care, the patient will be able to: maintain normal hemodynamic status as evidenced by a normal intake and output

Intervention 1. Monitor patients vital signs, especially the blood pressure To obtain baseline data and prevent hypotension 2. Assess patients level of consciousness A change in the level of consciousness indicates a decrease in circulating blood volume 3. Monitor intake and output To determine fluid balance and prevent dehydration 4. Regulate intravenous fluids appropriately To prevent dehydration and correct the normal hemodynamic status 5. Monitor hematocrit and

Evaluation February 11, 2010 @ 10:30 PM Goal Met Within the 8 hours span of care, the patient was able to maintain normal hemodynamic status as evidenced by a normal intake and output

noted
-

Decreas

ed platelet count of 115 x103 /uL (Normal: 150-400 x103 /uL) Gastric

lavage ordered

Date /Time February 11, 2010 5:00pm

Cues Objective Cue: - Increased body temperature of 38.3 touch sed respiratory rate of 24 diagnos Increa Skin

Needs N U T R I T I O N A L

Nursing Diagnosis Hyperthermia related to the release of endogenous pyrogen secondary to presence of CAP and liver cirrhosis R: Hyperthermia is the elevation of body temperature above normal range. Most often, it results from infection somewhere i the body, but it may be caused by other conditions (cancer, allergic reactions, and CNS injuries). Macrophages, white blood cells, and injured cells release chemical substances called pyrogens that act directly on the hypothalamus, causing its thermostat to be set to a

Objective/Goal Within my 1-3 hour span of care, my patients body temperature will decrease from 38.1C to 36.5-37.5C. 2. 1. signs.

Intervention Monitor patients vital

Evaluation February 11, 2010 @

serves as baseline data Note chronological and 8:00pm GOAL MET Patients body temperature 3. bath promotes heat loss by evaporation and conduction 4. Limit clothing in Provide tepid sponge decreased from 38.1 C to 36.7 C

developmental age of client. Elderly or impaired individuals ay not be able to recognize and/or act on symptoms of hyperthermia

is warm to

M E T A B O

is of CAP

lightweight, loose-fitting clothes. encourages heat loss by

ascites

L I C P A T T E R N

higher temperature. Reference: Nurses Pocket Guide 10th Edition by Doenges, et al.

radiation and conduction. 5. Cool the environment

with air-conditioning or fans. promotes heat loss by convection 6. dry. to reduce shivering 7. Administer replacement Keep clothing and linens

fluids and electrolytes to replace fluids lost through perspiration and respiration. 8. Maintain bedrest

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

 To prevent dehydration INTERDEPENDENT 10. Collaborate with

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

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

DEPENDENT 12. Administer antipyretics,

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

oxygen as ordered. to offset increased oxygen demands and consumption. 14. Administer replacement

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

DATE/ CUES TIME F E B R U A R Y -dyspnea - ascites -dry, scaly and shiny -edema Objective:

NEE D

NURSING DIAGNOSIS Fluid

OBJECTIVES OF CARE Within 8 hours span of care, the client will be able to :

NURSING INTERVENTIONS

EVALUATION

N U T R I T I O

Volume Excess in the interstitial space related to liver organ failure as evidenced by ascites In patients with liver failure, there is a decreased production of albumin. Thus, resulting to decrease in osmotic pressure in the intravascular spaces. This leads to the accumulation of fluid in the

1.

Measure vital signs

February 11, 2010 @

To obtain baseline date and a. Stabilize fluid volume as evidenced by balanced I/O, Vital signs within normal limits 2. Assess for evidence of to note any unusualities 11:00 pm Goal Unmet Patient was unable to:
o

dependent venous pooling or venostasis. To determine causative factors 3. Provide quiet

stabilize fluid volume as evidenced by imbalance intake and output

1 1 ,

N A L -

environment, limiting external stimuli. To promote adequate rest and comfort for faster recovery 4. Monitor intake and output

2 0 1 0 @

M E T A B

To determine elimination o

Date / Time February 11, 2010 at 4pm

Cues

Needs

Nursing Diagnosis w/ Rationale

Objective of Care Within my seven hours span of care, the patient will maintain undamaged physical Skin integrity by not manifesting signs of decubitus ulcer.

Nursing Intervention w/ Rationale 1. Monitor patients vital signs. serves as baseline data 2.) Assess for any changes in skin. to be able to determine the causative factors 3.) Note and record degree of jaundice of skin and sclera and scratches on the body. to be able to assess skin integrity 4.) Maintain strict skin hygiene. to prevent the spread of bacteria and prevent infection 5.) Provide adequate clothing/covers.

Evaluation

Objective: Jaundice noted in the skin upon inspection . +4 pitting edema noted on all four extremitie s (+) body malaise Vital Signs: BP- 110/70

N U T R I T I O N A L

Risk for impaired skin integrity related to prolonged bed rest R: When edema and jaundice are present, the skin is placed at more risk of being impaired because of the bilirubin present on the blood. Moreover, prolonged bed rest can form decubitus ulcers at the patients back.

February 11, 2010; 10pm

Goal Met: After seven hours span of care, the patient still maintained intact skin integrity as evidenced by absence of decubitus ulcer at the patients back.

Reference :

to prevent vasoconstriction

mmHg PR- 96 bpm RR- 24 cycles per minute TEMP. 38.3 C

M E T A B O L I C

Nurses Pocket Guide 11th Edition by Doenges, et al.

6.) Observe for reddened/blanched areas and institute treatment immediately. : Reduces likelihood of progression to skin breakdown. 7.) Change patients position every two hours. : To relieve the pressure on the patients back. 8.) Drain urine bag every two hours. To monitor output of patient in order to determine fluid and electrolyte intake and loses 9.) Encourage frequent skin care to significant other. Also, perform morning care to patient by performing complete bed bath and apply lotion afterwards. : To promote hygiene and skin

P A T T E

R N

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

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

R: The family is in grieving stage and so nurses should be sensitive enough in dong responsibilities Ask permission to the patient before removing tubing from his body

R: It is to convey respect and value to the patients body Use caution when removing tape from the body to avoid skin breakdown.

R: The body temperature decreases with a resultant lack of skin elasticity Elevate the head to prevent discoloration from the pooling of blood.

R: a physiological change will happen in which a bluish purple discoloration that is a by-product of red blood cell destruction occurs in the dependent areas in the body. The nurse should close the eyelids, insert dentures, close the mouth and position the body in a natural position as soon as possible after death. R: To prevent the body from stiffening caused by contraction of skeletal and smooth muscles. Prepare the body: remove all tubes and position the body

R: To make the body look comfortable and natural for family viewing. Place the body in a plastic or fabric shroud and put a tag on it.

R: To prepare the body for transport to the morgue. Return the deceaseds possession to the family such as jewelries, eyeglasses, clothing and all personal items. Offer to contact support people Help the family with decision making regarding funeral home, transportation, and the removal of the deceaseds belongings. R: The family needs help since they are on the process of grieving. Demonstrate compassion in providing information and support to families.

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

PROGNOSIS

Criteria Onset of Illness

Poor

Fair

Good

Justification We rated it poor since the patient started manifesting symptoms that are associated with liver cirrhosis since December 2009. On January 23, 2010, 13 days prior to his admission, the patient experienced headache, chest pain, dull abdominal pain, felt nauseated and dizzy..

Duration of Illness

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

Attitude and

As verbalized by his wife,

willingness to take medications

the patient is taking medications but sometimes with skipped doses because he neglects to take and due to forgetfulness.

Age

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

Precipitating and predisposing factors

We rated it poor since his age and race predisposes him in developing the disease. Moreover, his chronic alcoholism precipitates the development of the disease. Longtime alcohol beverage drinking is

the most common factor that triggers liver cirrhosis. Environment The ward has poor ventilation, crowded and noisy. With this, it is not favorable for recovery. Family Support Family support is fair. They give time in giving care to the patient but cannot provide all the needs especially the medications and mechanical ventilator because of financial inadequacy.

Basis for Prognosis: Poor = 1 Range of prognosis: 0-1.50 = poor 1.51-2.0 = fair 2.0-2.5 = good

Fair = 2

Good = 3

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

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

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

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

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

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

REFERENCES

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

12, 2010.

HANDBOOK OF MEDICAL-SURGICAL NURSING 3RD ED. SPRINGHOUSE: 2006 LEIGHTON, S.S., ET AL.(1997) PERSPECTIVE IN HUMAN DEVELOPMENT. RETRIEVED FROM HTTP://WWW.SLIDESHARE.NET/SUNNYCUTS/JEAN-PIAGETS-THEORIES-OF-DEVELOPMENT. RETRIEVED ON FEBRUARY 20, 2010. LINDON, P.S & REESE, R.R. ( 1999) PSYCHOLOGY: APPROACH AND UNDERSTANDING. RETRIEVED
FROM HTTP://PSYCHOLOGY.ABOUT.COM/OD/THEORIESOFPERSONA LITY /A/PSYCHOSOCIAL_3 .HTM. RETRIEVED ON

FEBRUARY 12, 2010.

LINDON, P.S & REESE, R.R. ( 1999) PSYCHOLOGY: APPROACH AND UNDERSTANDING. RETRIEVED FROM HTTP://EDUCATION.STATEUNIVERSITY .COM/PAGES/2032/HAVIGHURST-ROBERT-J-19001991.HTML. RETRIEVED ON FEBRUARY 12, 2010. LUCKMANN, K.L & SORENSEN, W.A (2003) : MEDICAL-SURGICAL NURSING: A PSYCHOPHYSIOLOGIC APPROACH. LOUIS, MISSOURI: MOSBY. MCTIMOTHY, A.S (2005) PATHOPHYSIOLOGY: A 2-IN-1 REFERENCE FOR NURSES. PHILADELPHIA: LIPPINCOTT WILLIAMS & WILKINS. PETERSON, M.L, LUIS, B.D. & CHONG, P.C.(2000)PERSONALITY DEVELOPMENT. RETRIEVED FROM HTTP://BAMA.UA.EDU/~JSTALLWO /YAL/ARTICLES/YOUNG%20ADULT%20LITERATURE%20IN %2 0THE%20CLASSROOM.PDF. RETRIEVED ON FEBRUARY 22, 2010.

REYBURN, S. W. (2001) MANUAL OF MEDICAL EDUCATION. RETRIEVEDFROM HTTP://WWW .AAFP.ORG/AFP /2006/0201/P44 2.HTML ACCESSED ON FEBRUARY 21, 2010 SUDDARTH, D.R. (1991) THE LIPPINCOTT MANUAL OF NURSING PRACTICE, 5TH ED. PHILADELPHIA: LIPPINCOTT WILLIAMS & WILKINS. WONG, L.D. (2000) UNDERSTANDING LIVER CIRRHOSIS. RETRIEVED FROM
HTTP://WWW.EMEDICINEHEALTH.COM/CIRRHOSIS/PAGE2_EM.HTM#CIRRHOSIS%20CAUSES.

RETRIEVED ON FEBRUARY 22, 2010.