1

Table of Contents

Introduction

Biographical Data

Health History

Past

Present

Functional Health Patterns

Genogram

Psychopathophysiology

Physical Assessment and Review of Systems

Diagnostic and Laboratory Results

Normal Anatomy

Nursing Process Records

Prognosis

Bibliography
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Introduction

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

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

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

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

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

cholesterol—and fat-soluble vitamins.

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

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

cells. A healthy liver is necessary for survival.

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

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

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

vessels on the skin.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

may be necessary for cirrhosis with complications.

 4

Biographical Data

Name: “Boy Bungot”

Room #: Male Ward 6

Age: 42 years old

Civil Status: Married

Occupation: Farmer

Address: P-5 Kianggat Dangcagan 8719 Bukidnon

Birthday: March 24, 1967

Sex: Male

Weight: 60.5 kg

Height: 5’5”

Nationality: Filipino

Religious Affiliation: Roman Catholic

Highest Educational attainment: 2nd year High school

Usual health care provider: Health Center

Date of confinement: February 01, 2010

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

Attending Physician: Dr. Chuvaness

Chief Complaints: Jaundice

Impression/ Diagnosis: R/I Liver Cirrhosis, Colelithiasis

 5

Health History

Past History

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

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

experienced measles, chicken pox and other illnesses.

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

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

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

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

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

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

his wrist. He was not hospitalized this time.

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

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

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

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

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

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

friends.

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

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

experienced sickness except from hang over.

 6

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

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

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

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

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

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

hospital for admission because the medications only cost 7 pesos.

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

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

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

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

did not go for admission.

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

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

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

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

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

This time, he also had fever and took Paracetamol but was not relieved. He also had

epigastric pain and feeling of fullness. This prompted him to go for check-up at Kibawe

Hospital and was diagnosed of UTI. He did not want to be admitted so he was prescribed

by the doctor these medications: Sambong 3x a day, Cotrimoxazole 2x, taken for 1 week.

Aside from UTI, he was also diagnossed of Liver Cirrhosis through ultrasound. His

doctor wanted to let him stay at the hospital so that he can be observed for further signs &

symptoms but he refused. The doctor prescribed him essentiale forte, Multivitamins,
 7

Aluminum chuvah, and antibiotics. Advised to reduce alcohol consumption and increased

fluid intake. But, he did not follow the advice of the doctor.

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

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

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

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

Present History

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Health Perception – Health Management

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

reach it.

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

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

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

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

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

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

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

have completed their immunization when his children were young.

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

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

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

Nutritional – Metabolic Health

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

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

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

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

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

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

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

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

a lot of alcohol than eating his meals.

Elimination

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

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

defecation. He defecates twice a day.

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

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

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

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

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

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

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

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

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

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

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

Sleep – Rest

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

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

sleeping. No problems in falling asleep whatsoever.

Cognitive – Perceptual

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

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

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

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

being drunk.

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

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

is his present goal.

Role Relationship

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

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

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

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

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

Sexuality

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

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

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

Coping Stress Management

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

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

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

mind off from his problems.

Value – Belief System

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

 PATERNAL MATERNAL

”Nerbyo
s” Alcoholi
c
Deceas Fatigu
ed
Hypertensi Smok
48 42 33 31
Lung
disease Patien
Liver UTI
cirrhosis
Review of General Health Status
Systems
The patient is 42 years old, male, and is married, and had 4 children. The patient is wearing a blue
and white striped hospital gown on the first visit. The patient weighed 60 kgs(Feb. 2 ,2010) and on
Feb. 3,2010 58kgs, upon admission 63kgs, ascites present with the abdominal girth of 39 on the 1st
day and 38 on the 2nd day. Height is 5’5. He also had bipedal pitting edema grade 2, has icteric
sclerae and is jaundice all over. He is conversant and witty, is alert and oriented to time, place and
person. Is experiencing weight loss. He had no mobility problems but he needs assistance upon
dressing because of the IV line, he can consume a cup of rice,1 serving of any kind of viand and a
cup of water every meal. He considers his health not in good condition because of his illness.

Areas/Syste ROS Physical Assessment/Examination

ms
Inspection Palpation Percussion Auscultation
Skin:
Integument The patient had no • jaundice, • CRT- 3 sec.
ary skin diseases • caput medusa • Poor skin
present such as • Cracked red turgor
rashes, sores, lips
ulcers, warts, or • Scaly
moles. There are no Nails:
skin tumors, • Pale,
masses, and (-)clubbing
bruises. Hairs are Temperature:
evenly distributed. Feb. 2,2010
Bathed daily with 10 pm-37.9
special skin care 2 am-37.8
preparation 6 am-37.5
(applying of lotion). Feb. 3, 2010
Nails are clean and 10 pm- 38.4
well trimmed. 2 am- 37.5
6 am-37.3

Head The pt experiences Head:

hangover after • Symmetrical • No lumps and
 • Can move up tenderness
drinking spree with and down, left noted
his companions. to right • Scalp freely
Two years ago had without pain movable
experience collapse Face: without
for 10 minutes • Jaundice lesions or
because prior at tenderness
night they had • Can do
drinking session different facial
with his friends. expressions
Hadn’t experience • Evenly
stiff neck or head distributed
trauma. hair

Eyes The patient is • Eyelashes and

already unable to Eyebrows are
read small letters. well
He does not wear distributed
any eyeglasses and • Icteric Sclerae
did not go for a • No lesions or
check-up with an inflammation
ophthalmologist. of eyelids
• Pupils equally
reactive to
light

Ears The patient had no External Ear:

history of hearing • Auricles are • No
disturbances. Had aligned with tenderness
not experience any eyebrows. noted
discharges or pain. • No pain upon
movement of
auricle and
tragus
• No discharges
noted
External Canal:
• No redness,
swelling,and
 discharges
noted

Nose and Experience colds if • No

Sinuses exposed to rain • Nasal cavities tenderness
sometimes are patent noted

Mouth and He had history of • Red, dry,

Pharynx alcoholism;every 15 cracked lips.
days he always buy • Dry buccal
1 long neck of mucosa,
tanduay rhum a day intact, no
for 3-4 days. He is prescence of
fond of eating meat lesion.
as well as salty and • Gums appear
fatty food. very red but
there are no
signs of
bleeding.

Neck No history of lumps • Freely moves • (-)pain

or swelling. Had not -chin to chest • (-)masses
experience stiff -bends head • (-)enlargemen
neck and any forward t of thyroid
limitation of motion. and backward gland
-side to side
 Laboratory and Diagnostic Test Results

Ultrasound

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

dilated. No focal lesions noted.

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

echogenic foci seen within its lumen. No wall thickening.

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

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

aorta.

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

Splenic hilum is unremarkable.

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

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

No focal lesions and calculi appreciated.

The urinary bladder is adequately filled showing regular contour and smooth

walls. No abnormal echoes or calculi no intraluminally.

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

calcifications appreciated here.

Impressions:

Liver Cirrhosis

Hepatospleenomegaly

Microcholecystolithiasis

Obscured extrahepatic ducts and pancreas

Prostate gland enlargement grade I by ultrasound criteria with concretions

 No free intraperitoneal fluid demonstrated

Sonographically normal intrahepatic ducts, kidneys, and urinary bladder

Urinalysis

Color: yellow Ketones: (++)

Transparency: hazy Specific Gravity: 1.015

Reaction: 6.5 Sugar: Negative

Albumin: negative

Pus Cells: 10-15

RBCs: 0-3

Diagnostic Normal Values Result Interpretation

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

LIVER:

Is the heaviest gland of the body, weighing about 1.4 kg in an average

adult. The liver is inferior to the diaphragm and occupies most of the right

hypochondriac and part of the epigastric regions of the abdominopelvic

cavity.

GALLBLADDER:
Is a pear shaped sac that is located in a depression of the posterior

surface of the liver. It is 7-10 cm long and typically hangs from the

anterior inferior margin of the liver.

The liver is almost completely covered by visceral peritoneum and is

completely covered by a dense irregular connective tissue layer that lies

deep to the peritoneum. The liver is divided into two principals lobes ---- a

large right lobe and a smaller left lobe---- by the falciform ligament, a fold

of the peritoneum. Although the right lobe is considered by many

anatomist to include an inferior quadrate lobe and a posterior caudate lobe,

based on internal morphology, the quadrate and caudate lobes more

appropriately belong to the left lobe. The falciform ligament extends from

the undersurface of the diaphragm between the two principal lobes of the

liver to the superior surface of the liver, helping to suspend the liver in the

abdominal cavity. In free border of the falciform ligament is the

ligamentum teres (round ligament), a remnant of the umbilicus. The right

and left coronary ligaments are narrow extension of the parietal

peritoneum that suspend the liver from the diaphragm.

The parts of the gallbladder include the broad fundus, which projects

inferiorly beyond the inferior border of the liver; the body, the central

portion;and the neck, the tapered portion.

HISTOLOGY OF THE LIVER AND GALLBLADDER

The lobes of the liver are made up of many functional units called lobules.

A lobule is typically a six-side structure that consist of specialized

epithelial cells, called hepatocytes, arranges in irregular, branching,

interconnected plates around a central vein. In addition, the liver lobule

contains highly-permeable capillaries called sinusoids, through which

blood passes. Also present in the sinusoids are fixed phagocytes called

stellate reticuloendothelial (Kupffer) cells, which destroy worn-out white

blood cells and red blood cells, bacteria, and other foreign matter in the

venous blood draining from the gastrointestinal tract.

Bile, which is secreted by hepatocytes, enters bile canaliculi, narrow

intercellular canals that empty into empty into small bile ductules. The

ductules pass bile into bile ducts at the periphery of the lobules. The bile

ducts merge and eventually form the larger right and left hepatic ducts,

which unite and exit the liver as the common hepatic duct. The common

hepatic duct joins the cystic duct from the gallbladder to form the common

bile duct. The functions of the gallbladder are to store and

concentrate the bile produced by the liver (up to ten folds) until it is

needed in the small intestine. In the concentration process, water and ions

are absorbed by the gallbladder mucosa

ROLE AND COMPOSITION OF BILE

Each day, hepatocytes secrete 800-1000 mL of bile, a yellow, brownish, or

olive-green liquid. It has a pH of 7.6-8.6 and consist mostly of water, bile

salts, cholesterol, a phospholipids called lecithin, bile pigments, and

several ions. The principal bile pigment is bilirubin. The phogacytocis of

aged red blood cells liberates iron, globin, and bilirubin. The ion and

globin are recycled; the bilirubin is secreted into the bile and is eventually
broken down in the intestine. One of its breakdown products stercobilin

that gives feces their normal brown color.

BLOOD SUPPLY OF THE LIVER

The liver receives blood from two sources. From the hepatic artery it

obtains oxygenated blood, and from the hepatic portal vein it receives

deoxygenated blood containing newly absorbed nutrients, drugs, and

possibly microbes and toxins from the gastrointestinal tract. Branches of

the hepatic portal vein, hepatic artery, and bile duct typically accompany

each other in their distribution through the liver. Collectively, these three

structures are called a portal triad. Portal triads are located at the corners

of the liver lobules.

FUNCTIONS OF THE LIVER

CARBOHYDRATE METABOLISM

When blood glucose is low, the liver can break down the glycogen

to glucose and released the glucose into the bloodstream. When the

glucose is high, as occurs just after eating a meal, the liver converts

glucose to glycogen and triglycerides for storage.

LIPID METABOLISM

Hepatocytes store some triglycerides; breakdown fatty acids to

generate ATP; synthesize lipoproteins, which transport fatty acids,

triglycerides, and cholesterol to and from body cells; synthesize

cholesterol; and used cholesterol to make bile salts.

PROTIEN METABOLISM
 Hepatocytes deaminate amino acids so that the amino acids can be

used for ATP production or converted to carbohydrates or fats.

PROCESSING OF DRUGS AND HORMONES

The liver can detoxify substances such as alcohol and excrete

drugs such as penicillin, erythromycin, and sulfonamides into bile. It can

also excrete thyroid hormones and steroid hormones such as estrogens and

aldosterones.

EXCRETION OF BILIRUBIN

Most of the bilirubin in the bile is metabolized in the small

intestine by bacteria and eliminated in feces\

SYNTHESIS OF BILE SALTS

Bile salts are used in the small intestine for the emulsification and

absorption of lipids.

STORAGE

Liver is a prime storage site for certain vitamins (A, B12, D, E, and

K) and minerals (iron and copper), which are released from the liver when

needed elsewhere in the body

PHAGOCYTOSIS

The stellate reticuloedothelial (Kupffer) cells of the liver

phagocytize aged red blood cells, white blood cells, and some bacteria

ACTIVATION OF VITAMIN D

The skin, liver, and kidneys participate in synthesizing the active

form of vitamin D.
Nursing Diagnosis: Imbalance Nutrition: Less than body requirements r/t abdominal distention & discomfort, anorexia
NANDA: Intake of nutrients insufficient to meet the metabolic needs
Cause Analysis: Nutritional status can be affected by disease or injury states; physical factors; social factors; or psychological factors.
-Gulanick & Myers. Nursing Care Plans:Nursing Diagnosis & Interventions 6th Ed. (2007) p. 134-135
Assessment NIC with Intervention Rationale Outcome Expected
NIC: Nutrition Therapy NOC: Nutritional Status
Subjective: ASSESSMENT:
-reports of weight loss from -Weighed daily. Instruct to -Weight is a good indicator of UNMET As Evidenced By
60kg to 58kg weigh @ least weekly @ home both nutritional status & fluid -no weight gain
-reports feeling of fullness balance. Short-termed weight
-verbalized of anorexia fluctuations tend to reflect fluid
balance, while longer term
changes in weight one more
Objective: reflective of nutritional status.
-weight from 60kg to 58kg (Lemone NCP, p.723)
-weight loss -Assessed dietary intake & -Identifies deficits in nutritional
-poor skin turgor nutritional status through diet intake & adequacy of
-scaly hx & diary & laboratory data nutritional state. (Smeltzer,
-cracked lips p.1323)
-edema (+) COMFORT MEASURES:
-jaundice (+) -Encouraged in between snacks -A small meal is more
-ascites (+) appealing. Between meal
snacks help maintain adequate
calorie & nutrient intake.
(Lemone, NCP p.323)

-Provide diet high in -Provides calorie for energy

carbohydrates with protein sparing protein for healing
intake consistent with liver
function.

-Elevate head of bed during -Reduces discomfort from

meals/place on comfortable abdominal distention &
position decreased sense of fullness
produced by pressure of

-Provide oral hygiene before
meals. Pleasant environment
for meals @ meal time
-Offer small more frequent
meals 6x a day
-Provide attractive meals & an
aesthetically pleasing setting at
meal time
TEACHINGS:
-Assisted patient in identifying
low-sodium foods
-Taught to eliminate alcohol
abdominal contents & ascites
on the stomach. (Smeltzer, Med
Surg.p.1323)
-Promotes positive
environment & increased
appetite, reduces unpleasant
taste. (Smeltzer, Med
Surg.p.1323)
-Decreases feeling of fullness,
bloating. (Smeltzer, Med
Surg.p.1323)
-Promotes appetite & sense of
well-being
-Reduces edema & ascites
formation. (Smelter, Med
Surg.1323)

-Eliminates “empty calories”

and further damage from
alcohol. (Smeltzer, Med
Surg.p.1324)
Care Plan Evaluation: The care plan needs more time to meet the goal of the intervention.
Nursing Diagnosis: Ineffective Breathing Pattern r/t increase intra-abdominal pressure on the diaphragm & reduced lung capacity 2⁰
Ascites
NANDA: Inspiration and or expiration that does not provide adequate ventilation
Cause Analysis: Ascites is the accumulation of fluid in the peritoneal cavity. Thus, causing pressure to the diaphragm that would
eventually restrict lung expansions interfering with efficient gas exchange & leading to hypoxia. –Lemone, p.562-
Assessment NIC with Intervention Rationale Outcome Expected
NIC: Airway Management NOC: Respiratory Status
Subjective: ASSESSMENT: ventilation
-reports of dyspnea & SOB -Monitored respiratory status -Ascites may cause pressure &
especially when on supine for changes in rate & depth, use increase the effort of breathing. -Partially met AEB:
position & is alleviated when pt of accessory muscles, & Depending on the severity &
is on sitting or fowler’s position increased work of breathing, amount of ascetic fluid, the depth Experiences improved
nasal flaring, & symmetric of the respirations may vary, & respiratory status
-reports of abdominal pain expansion chest expansion may be decreased
P-upon movement (Comer, S (2005) Delmar’s Still reports of minimal
Q-dull Critical Care Nursing Care plans, dyspnea
R-non radiating 2nd Ed. Thomson Delmar
S-6/10 Learning: Singapore, p.223) Exhibits normal respiratory
T-intermittent rate with no adventitious
-reports of fluid accumulation -Monitor for presence of cough -Liver failure may result in sounds
on the peritoneal cavity since and character of sputum abnormal coagulation, which in
turn can result in bloody Exhibits full thoracic
Objective: secretions. Atelectasis from excursion without shallow
-RR 3(Feb. 1, 2010 2 am 26 decreased chest excursion may respiration
cpm, 6 AM 31 cpm, Feb. 2, occur & result in infection
2010, 10 pm, 30 cpm, 2 AM 34 (Comer, S (2005) Delmar’s Experiences absences of
nd
cpm, 6 AM 30 cpm, Feb 3, Critical Care Plans, 2 Ed. confusion or cyanosis
2010, 10 PM 29 cpm, 2 AM 30 Thomson Delmar Learning:
cpm.) Singapore, p.224)
-use of accessory muscles
-nasal flaring - Auscultate lung fields for -Breath sounds may be decreased
-asymmetrical chest expansion adventitious breath sounds or because of decreased chest
-cough (-) rubs expansion from increasing ascites
-clear lung field
-fluid wave (+)
-abdominal girth
-shifting dullness (+)
-LOC pt is awake
-oriented to time, person &
place
-skin color, temp. ?
-Assess for thoracic or upper
abdominal pain
-Inquire about precipitating and
alleviating factors
COMFORT MEASURES:
-Encourage deep breathing &
coughing exercises
-Elevate head of bed to at least
30 degrees
-Conserve patient’s strength by
providing rest periods &
assisting with activities
-Change position every 2hrs
-Use pain management like
(divertional activities, guided
imagery) as appropriate
TEACHINGS:
-Explain all procedures before
(Comer, S (2005) Delmar’s
Critical Care Plans, 2nd Ed.
Thomson Delmar Learning:
Singapore, p. 224)
-These can result to shallow
breathing (NCP by Gulanic, p.30)
-Knowledge of this factors is
useful in planning interventions to
prevent or manage future episodes
of dyspnea (Gulanick,NCPp. 39)
-Improves lung expansion &
helps to remove secretions.
(Comer, S (2005) Delmar’s
Critical Care Plans, 2nd Ed.
Thomson Delmar Learning:
Singapore, p.224)
-Reduces abdominal pressure on
the diaphragm & permits fuller
thoracic excursion & lung
expansion. (Smeltzer, 1330)
-Reduces metabolic & oxygen
requirements. (Smeltzer, Med
Surg. 1330)
-Promotes expansion &
oxygenation of all areas of the
lungs. (Smeltzer, 1330)
-This allows for pain relief & the
ability to deep breathe. (Gulanick
NCP, p.31)
 performing -This decreases patient’s anxiety.
(Gulanick, NCP p. 31)
-Explain effects of wearing
restrictive clothing -Free movement of the chest wall
& abdomen is necessary for
-Teach pt. to pace activities & optional breathing. (Gulanick,
to avoid unnecessary tasks NCP p. 31)
when dyspneic -Energy conserving methods
reduces fatigue, dyspnea &
oxygen consumption.
(GulanickNCP, p. 31)
Care Plan Evaluation: Care Plan Evaluation: The care plan was effective because it enables the patient to verbalize his concerns on the
cause of the change in his appearance.
Nursing Diagnosis: Disturbed body image r/t changes in general appearance (Ascites, jaundice, peripheral edema)
NANDA: Confusion in mental picture of one’s physical self
Cause Analysis: Throughout the life span, body image changes as a matter of development, growth, maturation, changes related to
childbearing and pregnancy, changes that occur as a result of aging and changes that occur or are imposed as a result of injury or
illness.
-Gulanick & Myers. Nursing Care Plans:Nursing Diagnosis & Interventions 6th Ed. (2007) p. 21-
Assessment NIC with Intervention Rationale Outcome Expected
NIC: Body Image/Role NOC: Psychosocial
Subjective: Enhancement Adjustment: Life change
-Patient verbalized the changes
on his appearance especially ASSESSMENT:
the color of his eyes, and -Assessed changes in -Provides information for PARTIALLY MET As
presence of spider like blood appearance & the meaning assessing impact of changes in Evidenced By
vessels in the abdomen these changes have for patient appearance, sexual function, & -verbalized concerns related to
& family role on the patient & family. changes in appearance, life, and
(Smeltzer, p. 1327) lifestyle
Objective: -maintained good grooming
-ascites (+) -Assessed patient’s family’s -Permits encouragement of and hygiene
-jaundice (+) – skin & sclera previous coping strategies those coping strategies that are -verbalized that some of
-edema (+) bipedal familiar to patient & have been previous lifestyle practices
-cracked lips effective in the past. (Smeltzer, have been harmful
-scaly p. 1327)
-poor skin turgor COMFORT MEASURES:
-Encouraged patient to -Enables patient to identify &
verbalize reactions & feelings express concerns, encourages
about these changes patient & significant others to
share these concerns.
(Smeltzer, p. 1327)

-Assisted & encourage patient -Encourage patient to continue

to maximize appearance & safe roles & functions while
 explore alternatives to previous
role function
-Assisted patient in identifying
short-term goals
-Encourage & assist patient in
decision making about care
-Identify with patient resources
to provide additional support
Care Plan Evaluation: The care plan was effective because it enables the patient to verbalize his concerns on the cause of the change in
his appearance.
encouraging exploration of
alternatives. (Smeltzer, p.
1327)
-Accomplishing these goals
serves as positive
reinforcement & increased self-
esteem. (Smeltzer, 1327)
-Promote patient’s control of
life & improves sense of well-
being & self-esteem. (Smeltzer,
p. 1327)
-Assist patient in identifying
resources & accepting
assistance from others when
indicated. (Smeltzer, p. 1327)
Nursing Diagnosis: Fluid Volume Excess: Third Space fluid shift r/t decreased production of albumin
NANDA: It is increased isotonic fluid retention
Cause Analysis: Cirrhosis of the liver impairs aldosterone metabolism & alters renal perfusion, leading to increase salt & water
retention.
–Porth p.866
Assessment NIC with Intervention Rationale Outcome Expected
Subjective: NIC: Fluid/Electrolyte NOC: Fluid Balance
-patient verbalized an increased Management
in the abdominal girth and PARTIALLY MET As
presence of fluid in the stomach ASSESSMENT: Evidenced By:
and edema on the peripheral -Recorded intake & output of -Indicates effectiveness of tx & -Exhibited no rapid increase in
-Usual weight as reported was 1-8hrs depending on response adequacy of fluid intake. weight
68 kg. to interventions to interventions (Smelter,Med-Surg 1332) -consumed diet low in sodium
& on patient activity. and within prescribed fluid
restriction
Objective: -Measured & record abdominal -Monitors changes in ascites -exhibited decreasing
-concentrated urine girth & weight daily. formation & fluid abdominal girth
-presence of dullness upon accumulation. (Smeltzer,Med-
percussion Surg p.. 1332)
-fluid wave upon palpation
-Peripheral edema (+) -Monitor electrolytes, hgb, & -Diuretics may cause
Grade II pitting Hct electrolyte imbalances,
-Weight from Feb 2, 2010 60kg shunting may cause
to 58kg (Feb 3, 2010) hemodilution. (Black & Hawks,
-Abdominal girth from (Feb Med SURG. p. 1357)
2. ) 38cm to (Feb 3. )37cm
-Assessed urine specific gravity -Specific gravity measures the
RR concentration of urine, an
Feb. 1, 2010: indicator of hydration.
2 am-26 cpm (LeMone NCP, p. 722)
6 am-31 cpm -Monitor albumin/protein -Protein molecules act as
levels “magnets” that help maintain
Feb. 2, 2010: body fluid in correct
10 pm-30 cpm compartments, low protein
2 am-34 cpm level allows shift of fluid to
6am-30 cpm extravascular space. (Gulanick,
p. 676)

Feb. 3, 2010: -Checked abdomen for dullness -Fluid in the Peritoneal cavity
10 pm- 29 cpm on percussion may produce a dull sound on
2 am- 30 cpm percussion. (gullanick NCP p.
676)

Labs.:
Hgb. 9.0 -Assess for signs of portal -Portal hypertension is high
Hct. 29 hypertension hx of upper GI blood pressure within vascular
bleeding & spider nevi bed, which is usually a high
Urine Specific Grav. 1.015 flow, low-resistance vascular
Urine Albumin: Negative system. As cirrhosis progresses,
(-) signs of UGIB normally distensible

-Assessed breathing patterns -Ascites may limit excursion of

the diaphragm on inspiration.
The patient may hypoventilate
in a supine position

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

-Implement measures to -Edema causes skin to

prevent skin breakdown breakdown faster. (Black &
Hawk, p. 1353)

-Administered medications as
 ordered:
Lasix, Apo-furosemide - Competitively blocks the
effect of aldosterone in the
renal tubule, causing loss of
sodium and water and retention
of potassium.

NIC 2 : Medication
administration
Spironolactone Inhibits the reabsorption of
sodium and chloride from the
ascending limb of the loop of
Henle leading to the sodium
rich diuresis.
Assessment:
-monitor I&O ratios and daily -Promotes patient’s
weight throughout therapy. understanding of restriction &
cooperation with it. (Smeltzer, )

TEACHINGS:
-Explained rationale for sodium
& fluid restriction.
Care Plan Evaluation: The care plan was very effective because it really helps the patient especially in monitoring his fluid volume
however it still needs more time in the implementation of the care plan.

Nursing Diagnosis: Risk for ineffective protection: bleeding r/t altered clotting mechanisms
NANDA: Decrease in the ability to guard self from internal or external threats such as injury or bleeding
Cause Analysis: In hepatic dysfunction, the production of blood clotting factors by the liver is reduced, leading to an increased
incidence of bruising, epistaxis, bleeding from wounds, and GI bleeding. Decreased production of several clotting factors may be
partially due to deficient absorption of Vit. K from the GI tract. This probably is caused by me inability to liver cells to use Vit. K to
make prothrombin. (Smeltzer p. 1307)
Assessment NIC with Intervention
NIC: Bleeding precautions
Subjective: ASSESSMENT:
-Monitor for V/s; report
tachycardia or hypotension.
-Monitor coagulation studies
and platelet. Report abnormal
result.
-Observe each stool for color,
consistency and amount
-Observe for hemorrhagic
Objective: manifestations. Ecchymosis,
Protime Control 11.5 secs. epistaxis, petechiae, and
INR= 2.6 bleeding gums.
Feb. 2 2010
BP:10 PM 100/80 mmHg
2 AM 110/80 mmHg -be alert for symptoms of
6 Am 100/60 mmHg anxiety, epigastric fullness,
Feb 3, 2010 weakness and restlessness
10 PM 110/70 mmHg
2 Am 110/70 mmHg
6 Am 100/70 mmHg
RR : Feb 1, 2010 COMFORT MEASURES:
2 am 26 cpm -Institute bleeding precautions
6 am 31 cpm * prevent constipation
Feb 2 *avoid injections; if needed,
10 Pm 30 cpm use small gauge needle and
2 AM 34 cpm apply gentle measure
6 AM 30 cpm * energy requirements (Smeltzer
Feb. 3, 2010 -Give frequent, small feedings
Rationale Outcome Expected
NOC: Cognitive Orientation
Partially met as evidence by:
-Identifies onset of problem
and potential trend. (Delmar the patient would identify at
NCPpp.221) least 3 reasons for precautions
with the use of his medications.
-Increases serum ammonia may Partially Met as evidenced
indicate increasing by:
encephalopathy. (Delmar would not exhibit absence of
NCPpp.221) restlessness and other
-Rapid wrist flapping when indicators of hemorrhage and
arms are raised in from the shock.
body with hands dorsiflexed
may indicate presence of
encephalopathy. (Delmar
NCPpp.222)
-Provides initial baseline from
which to gauge deterioration in
status. As encephalopathy
worsen, pt. LOC and ability to
cooperate diminish to the point
of coma. (Delmar NCP pp.
222)
-Reduces source of ammonia
(Smeltzer Med.-Surg.p.1328)
-Promotes consumption of
adequate carbohydrates for
Med Surg p.1328)
10Pm 29 cpm of carbohydrates. -minimizes risk for further
Feb 4, 2010 increase in the metabolic
2 am 30 cpm requirements. (Smeltzer, Med
-Protect from infections. Surg. p. 1328)
No BM since Admission -minimizes shivering, which
Hemorrhagic manifestations: would increase in metabolic
(-) ecchymosis requirements (Smeltzer, Med
(-) petechiae -Keep environment warm and Surg p. 1329)
(-) bleeding gums draft-free. -minimizes pt’s activity and
(-) anxiety metabolic requirements
(+) epigastric fullness -Limit visitors. (Smeltzer Med Surg, p. 1329)
(+) restlessness -provides stimulation to the
(-) weakness patient and opportunity for
serving the patient’s level of
-Awake at intervals (q2-4H) to consciousness. ( Smeltzer Med
assess cognitive status. Surg, p. 1329)

-If possible, have pt. write a -as hepatic failure progresses,

name each day and do simple
mathematic calculation.
the ability to write becomes
more difficulty and writing
becomes illegible @ pre-coma
stage inability to perform
mental calculations may
indicate worsening failure.
(Delmar NCP p. 221)
Care Plan Evaluation:
The Care of plan needs more time to meet the goal of intervention.
 Prognosis

Any patient with cirrhosis carries a risk of specific life-threatening complications such as

variceal bleeding, sepsis, or hepatorenal syndrome. There is also a significant risk of nonspecific

life-threatening complications due to the frequent association of comorbidities. The general

course of the disease is characterized by a longstanding phase of compensated cirrhosis, followed

by the occurrence of specific complications. It has been shown that 10 years after diagnosis, the

probability of developing decompensated cirrhosis is ∼60%, ascites being the most frequent

complication (∼50%).[1] Once patients have developed the first episode of decompensation,

complications tend to accumulate and life expectancy is markedly reduced. A schematic

representation of the course of cirrhosis according to four consecutive clinical stages is shown in

Table 1 .[2]

Table 1. Schematic Representation of the Outcome of Cirrhosis According to Four

Consecutive Clinical Stages*

The course of cirrhosis is extremely variable from patient to patient due to several factors,

including hepatic synthetic function (or “hepatic reserve”), the cause of cirrhosis, the possibility

of stopping or slowing the underlying damaging process to the liver, and the occurrence of liver

malignancy. Therefore, establishing a prognosis in a given patient with cirrhosis remains a

challenging issue. In addition to the simple estimation of life expectancy, more complex issues

must be taken into account, such as the capacity of a cirrhotic patient to withstand a given

therapeutic intervention, or whether a given therapeutic option offers an acceptable chance of

survival. Over the last couple of decades, additional complex issues have emerged with the
generalization of liver transplantation, namely, the optimal timing for transplantation and, on a

collectivity basis, the optimization of allocation policy in a context of organ shortage.

Even though the course of cirrhosis varies according to several factors, the need for prognostic

models and scoring systems is obvious in order to manage individuals faced with different

therapeutic options. Scoring systems are even more crucial for managing populations of patients

in the setting of transplantation, for instance. Major efforts have been made in recent years to

achieve these goals and develop prognostic tools which are detailed below. Hepatocellular

carcinoma (HCC) will not be discussed in this article.

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