A CASE PRESENTATION ON LIVER CIRRHOSIS

Presented to the Faculty of the School of Nursing

Adventist Medical Center College
Brgy. San Miguel, Iligan City

HADJI JAMEL, RIHAM M.

In Partial Fulfillment
of the Requirements for the Degree
BACHELOR OF SCIENCE IN NURSING

FEBRUARY 2019
 TABLE OF CONTENTS

I. TITLE PAGE _ _ _ _ Page

II. TABLE OF CONTENTS
III. LIST OF TABLES
IV. LIST OF FIGURES
V. OBJECTIVES
General Objective
Specific Objectives
VI. DEFINITION OF TERMS
VII. INTRODUCTION
VIII. NURSING HEALTH HISTORY
Vital Information (Personal Data)
History of Present Health Concern
Past Health History
Family Health History (Genogram)
Physical Examination and Review of Systems (PEROS)
Gordon’s Functional Health Patterns Assessment
IX. NORMAL ANATOMY AND PHYSIOLOGY
X. CONCEPT MAPPING
XI. NURSING CARE PLANS
XII. DISCHARGE PLAN
XIII. REFERENCES
XIV. APPENDICES
Diagnostic Tests
Drug Study
 LIST OF TABLES
TABLES PAGES
1 Physical Examination and Review of Systems

2 Normal Anatomy and Physiology

3 Nursing Care Plan

 LIST OF FIGURES

FIGURE PAGE

1 Genogram Showing the Family History

 OBJECTIVES

General Objective:

At the end of one and a half - hour case presentation, the participants will be able to
understand the disease process of Liver cirrhosis and its management.

Specific Objectives:

At the end of one and a half-hour case presentation, the participants will be able to:

1. Explain the medical terms related to the case;

2. Summarize the risk factors, manifestations, and complication of Liver cirrhosis;

3. Outline the nursing health history data;

4. Relate the anatomical structures and functions involved in an Liver cirrhosis disease;

5. Construct a concept map for Liver cirrhosis; and

6. Formulate a nursing care plan for a client with Liver cirrhosis

7. Organize a discharge plan;

8. Outline diagnostic tests for Liver cirrhosis; and

9. Enumerate the drug study on Liver cirrhosis.

 DEFINITION OF TERMS

The following terms are operationally and conceptually defined for better understanding

of the study.

Liver cirrhosis. A chronic hepatic disease, cirhossis is characterized by diffuse

destruction and fibrotic regeneration of hepatic cells. As necrotic tissues yields to fibrosis, this
disease alters liver structures and normal vasculature, impairs blood and lymphflow, and
ultimacy causes hepatic insufficiency.

Ascites. An abnormal accumulation of fluid in the abdominal cavity, seen often in

cirrhosis of the liver

Jaundice. Yellowish discoloration of the skin and eyes due to bile pigments in the blood.

Anorexia. Lack of desire for food.

Steatorrhea. Fatty feces

 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. 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. Function of the liver: the liver plays a crucial role in metabolism and
has a multitude of functions: Digestion and section, storage and processing of nutrients,
detoxification of harmful chemicals, and synthesis of new molecules.

Digestion bile neutralizes stomach acid and emulsifies fats, which facilitates for
digestion. Excretion bile contains excretory products, such as cholesterol, fats, and bile pigments
(e.g., bilirubin), that result from hemoglobin breakdown. Nutrient storage liver cells remove
sugar from the blood and store it in the form of glycogen, they also store fat, vitamin (A, B, D, E,
K), copper and iron. Nutrients conversion liver cells convert some nutrients into other, for
example amino acids can be converted to lipids or glucose, fats can be converted to
phospholipids, and vitamin D is converted to its active form. Detoxification of harmful
chemicals liver cells remove ammonia from the blood and convert it to urea, which is eliminated
in the urine, other substances are detoxified and secreted in the bile or excreted in the urine.
Synthesis of new molecules the liver synthesizes blood proteins, such as albumin, fibrinogen,
globulins, and clothing factors. An important contributor to the liver’s digestive functions is bile.
The liver produces and secretes 600-100 ml of bile each day. Bile is important for digestion
because it dilutes and neutralizes stomach acid. Bile also dramatically increases the efficiency of
fat digestion and absorption. Digestive enzymes cannot act efficiently on large fat globules. Bile
salts emulsify fats, breaking the fat globules into smaller droplets, much like the action of
detergents in dishwater. Bilirubin is a bile pigment that result from the breakdown of
hemoglobin. Gallstone may form if the amount of cholesterol secreted by the liver becomes
excessive and is not able to be dissolve by the bile salts.

Liver cirrhosis is derived from the 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 casesare idiopathic,i.e.,, of unknown
cause. It may be classified by the structural changes that take place or by the cause of the
disorder.

Cirrhosis of the liver can be divided into several types, depending on the cause of the
disease:Laennec’s or alcoholic cirrhosis ( caused by alcoholism), Postnecrotic cirrhosis (caused
by viral hepatitis and certain drugs chemicals), Billiary cirrhosis ( also called cholestatic : caused
by chronic biliary obstruction, usually from gallbladder diasease. And last is the Cardiac
cirrhosis ( caused by heart failure as a rare complication). Common problem and complications
associated with hepatic cirrhosis depend on the amount of damage sustained by the liver. In
compensated cirrhosis, the liver is scarred but can still perform essentialfunctions without
causing major symptoms. In decompensated cirrhosis, liver function is imapaired with obvious
manifestation of the liver failure. The loss of hepatic function contributes to the development of
metabolic abnormalities. Hepatic cell damage may lead to these common complications such as
Portal hypertension, ascites, bleeding esophageal varices, coagulation defects, jaundice, portal-
systemic encephalopathy with hepatic coma, hepatorenal syndrome and spontaneous bacterial
peritonitis.

Internationally, liver cirrhosis is the 8thThe 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 is 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 . 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 Filipinos—in
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.
Vital Information

Code Name: Mr. Y

Age: 58

Gender: Male

Civil Status: Married

Date of Birth: 04/18/1960

Place of Birth: Lialangan, Lanao del Norte

Race: Filipino

Cultural or Ethnic Background/Group: Iliganon

Primary Language: bisaya

Secondary Language: Tagalog

Religion: Roman catholic

Highest Educational Attainment (Client): College undergraduate

Occupation: Farmer, Barangay Captain

Highest Educational Attainment (Spouse): Elementary graduate

Occupation : Housewife

Usual Health Care Provider/s: N/A

Date of Admission: February 17, 2019 at 1:15 pm

Date of Discharge: N/A

Source/s of History: chart- 50 %, SO- 20%, Patient-30%

Reason/s for Seeking Health Care: Fever and cough

Primary Attending Physician: Dr. Melanie Felicia Bascug

Initial Impression/Diagnosis: COMMUNITY ACQUIRED PNEUMONIA

MODERATE RISK
Attending Physician:

Final Diagnosis:

CAPAcute kidney injury decompensated

liver cirrhosis
NURSING HEALTH HISTORY

A. Chief complaint: fever and cough

B. HISTORY OF PRESENT HEALTH CONCERN

5 Days PTA, onset of fever, consistent, temp. of 39.c with no other associated
symptoms. Patient took paracetamol with provided relief after 2 days.

5 days, PTA, onset of cough, non-productive, no medication taken. Night PTA, cough
was non-productive with yellowish sputum then PTA condition with associated with
shortness of breath which prompted admission.

C. PAST HEALTH HISTORY

Mr. Y was born on march 18 1960 at Tubod Lanao del Norte via normal vaginal delivery at
home deliver by quack doctor. During his childhood, he had only cough, fever, and
completed her immunization. No history of accidents or injuries. He start smoke at age of 16.
He consumed 1 pack a day and he drink 5 bottles of beer every week.

On January 26, Mr. Y was admitted at AMC-Iligan due to shortness of breathing,

yellowish of the skin. She was confined in the ICU due to
 PHYSICAL ASSESSMENT AND REVIEW OF SYSTEMS

AREAS ASSESSED DAY 1 PROBLEM IDENTIFIED

General health survey o Subjective findings:

“Galisod kog ginhawa” Activity intolerance
“Hawoy akong lawas” Fatigue
“wala koy gana mokaon” Ineffective breathing pattern
Imbalanced nutrition
Objective findings:
-Vital signs:
T:36.2-36.4
BP:130/80-130/70
PR:62-68
RR:20-22 O2S: 98-100
o Venoclysis mainline on left
metacarpal vein PNSS 1 L
@40cc/hour via infusion pump
o C hooked side drip of amenoleban
o C side dripHuman albumin 20% vial +20
mg Furosemide per vial to run for
2hrs q12hr
o O2 inhalation @2L/min via nasal
cannulas

Impaired skin integrity

(+) Body weakness Fluid volume excess
(+) Weak appearance Disturbed body image
(+) Pale skin
(+) Ascites
(+) Jaundice
(+) Wt. loss
(+) Loss of appetite

Integumentary system Subjective findings:

“Gadako na na iyang tiyan” as
verbalized by SO

Fatigue
Objective findings: Fluid volume excess
(+) Pale skin Disturbed body image
(+) Pale nailbeds
(+) Ascites
(+) Jaundice

Lab test:
Ultrasound-whole abdomen
Impression: Moderate ascites, Liver
 cirrhosis

HEENT Subjective findings:

a) Head and face
b) Eyes Objective findings:
c) Ears (+) Weak in appearance Fatigue
d) Nose (+)Icteric sclera Disturbed body image
e) Oral Cavity (+)Dry oral mucosa and lips
Lab result:
Total Bilirubin: 441.82(1.7-2ul/L)
B1 or Indirect: 91.82 (1.7-17.1)
B2or direct: 350.20(0-3.4)

Neck Subjective findings: No problem Identified

“Di man sakit akong liog” as verbalized
by the patient”

Objective findings:
(-) stillness
(-) lumps
(-) vein engorgement

Respiratory system Subjective findings:

“Galisod kog ginhawa” as verbalized by
the patient Ineffective airway clearance
Objective findings:
o RR: 21-22 Ineffective breathing pattern

(+)fine crackles
(+) Productive cough
(+) DOB

Lab result:
X-RAY of the chest
Impression: Crowding of the lower lung
parenchyma due to diaphragmatic
elevation
The included upper abdomen was
opacified,likely ascites
Minimal cardiomegaly

ABG: Respiratory alkalosis

Cardiovascular system Subjective findings: Fluid volume excess
Objective findings:
PR: 62-68 bpm
RR: 21-23 bpm

(+)ascites
(+)Fluid retention

X-RAY of the chest -

Impression: Crowding of the lower lung
parenchyma due to diaphragmatic
elevation
The included upper abdomen was
opacified,likely ascites
Minimal cardiomegaly

Breast and Axilla Not assessed

Gastrointestinal system and Subjective findings:
the abdomen “Wala siyay gana mokaon” as
verbalized by SO Imbalanced Nutrition

Objective findings:
(+)Anorexia
(+)Steatorrhea

Genitourinary/ Reproductive Subjective findings:

system “Dark color iyang ihi” as verbalized by
SO”
Risk for infection
Objective findings:
(+) tea colored urine
Lab result:
Urinalysis:
No parasite seen

Musculoskeletal system Subjective findings: Activity intolerance

“Hawoy akong lawas” as verbalized by
patient Fatigue

Objective findings:
o Venoclysis mainline on left
metacarpal vein PNSS 1 L
@40cc/hour via infusion pump
o C hooked side drip of amenoleban
o C side dripHuman albumin 20% vial +20
mg Furosemide per vial to run for
2hrs q12hr
o O2 inhalation @2L/min via nasal
 cannulas

(+)Body weakness

Neurologic system Subjective findings:

No problem identified

Objective findings:
o Foul breath
o Disturbed sleep pattern
Lymphatic/ Hematologic Subjective findings:
system
Objective findings:
o Anemia
o Thrombocytopenia
Risk for bleeding
Anemia

Lab result:

RBC: 2.54(4-6X10 12/L)

Hematocrit: 0.29 (0.37-0.57
Hemoglobin: 96.0 (110-180g/L)
Platelet count: 120 (140-450x10
PROTIME
Patient: 20.5 seconds
Control:13.5 seconds
Activity: 66%

Endocrine system Subjective findings:

(Not Applicable)

Fluid volume excess

Objective findings:
o Hypoalbuminemia
(+)ascites

Lab result:
Albumin: 20.4(35-54ul/L)
Ultrasound-whole abdomen
Impression: Moderate ascites, Liver
cirrhosis
URIC ACID: 333.21(155-357umol/L)
SGPT : 55.16 (5-35U/L)
SGOT:172.80(8-40U/L)
CREATININE: 267.6(51-106umol/L)
Alkaline phosphate: 154.19(53-141U/
 Table 2

GORDONS FUNCTIONAL HEALTH PATTERNS ASSESSMENT

Health Patterns Before Hospitalization During Hospitalization

1. Health Perception and Mr. Y was admitted due to fever and - concerns for his health condition
cough.
Health Management Pattern -willing to accept and listen to
He was hospitalized at AMC-Iligan health teachings.
on January 26 due to SOB, yellowish
-patient understand that treatment
of the skin.
and admission were necessary for
Mr. Y was expecting that the hospital
further management.
will give right treatment and
management for her recovery. She
understand that the treatment and
admission were necessary for further
management.

2. Nutrition and Metabolism Mr. Y has a good appetite. He ate His diet is Low salt low fat
whatever her daughter cooks.
Pattern
He has poor appetite and consumed
He eats 3 times a day and is dried only ½ of food served
fish, vegetables, beef and chicken

He has known allergies and food

restrictions

3. Elimination Pattern Mr. Y Defecated 1-2 times a day He defecated 2-3 times a day with
yellow color and watery

He void 5-6 times a day

4. Activity and Exercise
Pattern
5. Cognition and Perception
Pattern
He urinates 5-6 times a day
He doesn’t exercise but he walk Confine to bed
always near in their house always as
he used it as an exercise .
Mr. Y was oriented to people, time Sometimes he is irritable, short
and place, responses to stimuli tempered.
verbally and physically.
He speak bisaya but he can
understand tagalog

6. Sleep and Rest Pattern He usually sleep 6-7 hours. Her He usually sleep at 8 hours; her
earliest time in going to sleep is at earliest time in going to sleep is at
11:00pm and wakes up at 5 am 8pm and wakes up in the morning

He takes a nap at 1pm for 30 minutes. He takes a nap at irregular time and
He feels rested and can sleep wakes up in taking medication
peacefully.
-
7. Roles and Relationships Mr. Y is living with her daughter and His wife and 2nd daughter is always
by his side for emotionally and
Pattern grandchildren
physical support.
He receives a positive
reinforcement and provided her
His family structure is extended.
comfort and reassurance.
His daughter stated that he spend his
times to their daughter and
grandchildren. They give their best to
manage and provide all the care and
comfort he need.

8. Sexuality and Reproduction Satisfied with his sexual relationship Confined to bed
Pattern
He is married with 6 children

9. Coping and Stress
Tolerance Pattern
He shares his problem to his wife and He deals with stress through
daughter
communicating with his family and
He able to handle problems
successfully most of the time relatives.

When he has a problem he usually

used to drink alcohol
10. Values and Belief Pattern Mr. Y go to church every Sunday Visited by the chaplain
with their family

Table 2

NORMAL ANATOMY AND PHYSIOLOGY

Normal anatomy structures with their descriptions and functions

Liver Process nutrients and pancreas, produce

secretions that empty into duodenum

Right lobe Separated from the left lobe above and in front
 by the falciform ligaments, and separated from
the caudate and quadrate lobes by the sulcus
for the vena cava
Left lobe Ligamentum venosum and ligamentum teres
divide the left lobe of liver from the right as
viewed from behind
Falciform ligament Visible on the front of the liver, divides the
liver into a left and much larger right lobe
Caudate lobe The liver is bounded below, by the porta
hepatis, on the right by the fossa for the
inferior vena cava and on the left by the fossa
for the ductus venous and the physiological
division of the kiver called ligamentum
venosum
Quadrate lobe An area of the liver situated on the under
surface of the medial sement left lobe, bounded
in front by the anterior margin of the liver
Porta Which is the “gate” through which blood
vessels, ducts, and nerves enter or exit the liver
Hepatic artery Delivers oxygenated blood to the liver, which
supplies liver cells with oxygen

Hepatic portal vein Carries nutrient-rich blood from the digestive

tract to the liver. Blood exits the liver through
hepatic veins
Hepatic veins Empty into the inferior vena cava
Hepatic duct Transport bile out of the liver
Portal triads lobules Which contains a portal vein, bile duct, hepatic
artery, and lymphatic vessels
Hepatic cords Formed by platelike groups of liver cells called
hepatocytes
Hepatocytes Are located between the center and the margins
of each lobule
Hepatic sinusoids Discontinuous capillary that is similar to a
fenestrated capillary, having discontinuous
endothelium that serves as a location for
mixing of the oxygen rich blood from the
hepatic artery and nutrient-rich blood from the
portal
Sinusoid epithelium Contains phagocytic cells that help remove
foreign particles from the blood
Central vein All lobes unite to form the hepatic veins, which
carry blood out of liver to inferior vena cava
Bile canaliculus Is a cleftlike lumen between the cells of each
hepatic cord.
Gallbladder Is a small sac on the inferior surface of the
liver that stores concentrated bile
Cystic duct From the gallbladder to form common bile
duct
Common bile duct The pancreatic duct
Duodenal papilla The location of the duct where the bile and
pancreatic juice empty into the duodenum via
the ampulla of vater

Diagnostic Tests

CBC AND PLATELET COUNT

Diagnostic Test Result Normal Values Interpretation

RED BLLOD CELL 2.64 4-6 x 10 12/L DECREASE
HEMATOCRIT 0.29 0.37-0.47 DECREASE
HEMOGLOBIN 96.0 110-180 g/L NORMAL
WBC 11.0 5-10 x 10 9/L INCREASE
SEGMENTERS 0.74 0.50-0.65 INCREASE
LYMPHOCYTES 0.22 0.25-0.35 DECREASE
STABS 0 0.05-0.10
MONOCYTES 0.04 0.03-0.07 NORMAL
EOSINOPHILS 0 0.01-0.03
BASOPHILS 0 0.01
PLATELET COUNT 120 140-450 x 10 9/L NORMAL
Diagnostic Test Result Normal Values Interpretation
O2 SATURATION 97.3 95-98 % NORMAL
PH 7.351 7.35-7.45 NORMAL
PO2 95.2 80-105 mmHg NORMAL
PCO2 17.9 35-46 mmHg DECREASE
BASE EXCESS -15.7 -2-+3 mmol/L INCREASE
HCO3 9.9 22-26 mmol/L DECREASE
TOTAL CO2 10.4 23-27 mmol/L DECREASE

Diagnostic Test Result Normal Values Interpretation

ALKALINE 250.26 53-128 U/L INCREASE
PHOSPHATE
ALBUMIN 20.4 35-54 U/L DECREASE
SGPT (ALANINE 55.16 5-35 U/L INCREASE
AMINO
TRANSFERASE)
SGOT (ASPARTE 172.80 8-40 Iu/L INCREASE
AMINO
TRANSFERASE)
CREATININE 267.55 71-115 umol/L INCREASE

Diagnostic Test Result Normal Values Interpretation

BILIRUBIN – 441.82 1.7-21 umol/L INCREASE
TOTAL
B1 OR INDIRECT 91.82 1.7-17.1 umol/L INCREASE
B2 OR DIRECT 350.20 0-3.4 umol/L INCREASE

Diagnostic Test Result Normal Values Interpretation

POTASSIUM 3.46 3.5-5.3 mmol/L NORMAL
SODIUM 132.3 135-148 mmol/L DECREASE

Stool analysis

February 11, 2019, 10 pm

Color: yellow Flagellates

Character: mushy negative

Occult blood: Negative ELISA for E. hystolytica

Pus cells: 0-1/HPF N/A

Mucus: negative

RBC/ hpf: 0

Amoebas: negative

Comments: no parasite seen

PROTIME (PROTHROMBIN TIME)

February 17, 2019, 20:21

Patient: 20.5 SECONDS

Control: 13.5 SECONDS

Activity: 66.0%

INR: 1.52

EXAMINATION: X-RAY OF CHEST PA VIEW

SOB

Chest X-ray PA view:

Follow up x-ray compared with the previous study done last January 25, 2019 showed persistent
streaky and band-like opacities seen at the right lower lung. Recent small band like opacity seen
at the left lower lung. The heart is minimally enlarged and transversely oriented. Calcified plaque
at the aortic wall. The diaphragm and costophrenic sulci are intact, highly placed. Bone spurs at
the articular edges of the thoracic spine.
IMPRESSION:

 CROWDING OF THE LUNG BASES DUE TO DIAPHRAGMATIC ADHESION

CONCOMITANT BIBASAL PNEUMONIA CANNOT BE RULED OUT.
 MINIMAL CARDIOMEGALY
 ATHEROSCLEROTIC AORTA
 THORACIC SPONDYLOSIS

EXAMINATION: ULTRASOUND-WHOLE ABDOMEN

The liver is still within normal size but exhibits diffuse coarse parenchymal echotexture and
nodular gland outline.
There is a 2 cm hypoechoic nodule seen at the right lobe, suggesting a cirrhotic nodule. Minimal
perihepatic fluid.
The portal vein is prominent. The intrahepatic and common bile duct are not dilated. CBD =
4mm, normal caliber.
The gallbladder is normal in size, with echofree lumen. The gallbladder wall is not abnormally
thickened.
The pancreas and spleen ( length = 11.83 cm  4.68 cm) are normal in size and configuration.
The abdominal aorta is normal in caliber with no abnormal focal dilation.
The kidneys are normal in sizes and location. Right kidney measure 12.2 cm  5.27 cm  4.11
cm (LWT), with parenchymal thickness of 1.47 cm. the left kidney measures. 10.84 cm v6.20
cm 4.71 m (LWT), with parenchymal thickness of 1.97cm. the renal parenchyma is normal in
thickness and echogenicity. No focal masses seen. The central echo in both kidneys are intact .
negative for lithiasis and pelvoliectasis. Both proximal ureters are not dilated . the para-renal
spaces are normal.
The urinary bladder is well filled with urine. No intravesical seen. The bladder mucosa is
smooth.
The prostate gland measure 2.78 cm  2.9cm 3.62 cm (LWT), with equivalent weight of 15
grams.
IMPRESSION:

LIVER CIRRHOSIS. Small 2 cm hepatic nodule at the right lobe. Cirrhosis nodule. Unchanged.

MODERATE ASCITES. Progression in volume compared with the previous study done last
January 25, 2019

SONOLOGICALLY NORMAL GALLBLADDER, BILLIARY DUCTS, PANCREAS,

SPLEEN, BOTH KIDNEYS, URINARY BLADDER, AND PROSTATE GLAND
 Discharge Plan

Name: Of Patient: Mr. Y

Age : 58

Gender: Male

Room #: 416

Date: February 21, 2019

Time: N/A

Chief Complaints: fever and cough

Diagnosis/impression:

LIVER CIRRHOSIS
COMMUNITY ACQUIRED PNEUMONIA MODERATE RISK
Attending Physician: Dr. Melanie Felicia Bascug

A. OBJECTIVES

1. Summarizes a simple and productive discharge plan

2. Verbalizes the alternative methods to be provided

3. Gains knowledge in preventing and managing the condition

4. Adheres religiously maintenance of medication

5. Modify her lifestyle to prevent recurrence of the condition

 1. B. METHOD Medications

Dosage
Name of Drug
Preparation Curative
(Generic and Route Side Effects Instructions
Frequency Effects
Trade Name)
Duration
Aminoleban 1 sachet in oral Nutritionalprod Hypersensitivity 
250cc bid ucts, : rareskin Assess patient’s
adultenteral eruptionsGI: condition beforestarting
occasional the therapy
nauseaand 
vomitingOthers:  
Occasional Be alert to
chills,fever and adversereaction.
headache 
 
Monitor temperature.

 
If GI reaction
occur,monitor
patienthydration

Vitamin k 1tab tid oral Anti- No known Monitor for frank and
hemorrhagic common occult bleeding
side effects (guaiac stools,
Fat soluble for this Hematest urine, and
vitamin drug emesis). Monitor
pulse and blood
pressure frequently;
notify physician
immediately if
symptoms of internal
bleeding or
 hypovolemic shock
develop. Inform all
personnel of patient's
bleeding tendency to
prevent further
trauma. Apply
pressure to all
venipuncture sites for
at least 5 min; avoid
unnecessary IM
injections
Lactulose 3occ tid oral Gastrointestinal diarrhea Effects are seen in 24-48 hrs
agent, •
hyperosmotic Do not self medicate with
laxative another laxative because of
slow onset
•
 Notify Dr if diarrhea
persists for more than 24
hrs, could be a sign of
overdose, and need for med
adjustment

Liverprime 1 cap tid oral nausea, vomiting,

diarrhea and
a0dominal cramps

Polynerv 500mg 1 cap oral Vitamin and Assessment and Drug

Itching Effects
OD minerals Feeling of BEFORE:
swelling of entire  Determine
body reticulocyte count,
Pruritus hct, Vit. B12, iron,
Urticaria
folate levels before
Weakness
Sweating beginning therapy.
Nausea  Obtain a sensitivity
Restlessness test history before
Tightness of the administration
throat  Avoid I.V.
Hemorrhage administration bec.
faster systemic
elimination will
reduce effectiveness
of vitamin.
DURING:
 Don’t give large doses
of vitamin B12
routinely; drug is lost
through excretion.
 Don’t mix parenteral
preparation in same
syringe with other
drugs.

Keto-analogue 1 tab tid oral Supplement hypercalcemia Take drug as prescribed

Warnthe patient about
Essential amino
 acids possible side effects and
how to recognize them
Give with food if
GI upset
occursFrequently assess
for hypercalcemia

kalvim 1 tab tid oral

NaHco3 1 tab tid oral Fluids, Hypernatremia If the patient exhibits

Electrolyte,Bl andserum os shortnessof breath
ood molarity,para and
Products,And venousadmini hyperpnea,immediate
Hematological strationsmay ly inform
Drugs lead to thephysician.
tissuenecrosi •
s Inform physician if
relief is notobtained
or if the
patientdemonstrate
any
symptomssuggest
bleeding, such as
blacktarry stools or
coffee groundemesis.
•
Caution patient to
immediatelyreport to
physician if
symptomssuch as
nausea, vomiting
andanorexia occurs

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 2. EXERCISE/ACTIVITY and HOME ENIVRONMENT

1. Depending on the status, the patient is encouraged to return to usual activities gradually.

a) Encourage the patient and instructed the significant others to control activities for daily living

b) Encourage the patient and instructed the significant others to participate in passive active
range of motion as tolerated

c) Instructed the significant others to provide safety precautions to the patient, especially when
ambulating or using a bathroom

d) Instructed the significant others to include 30 minutes of walking as tolerated

e) Encourage patient to include at least 30 minutes of walking

RESTRICTIONS:

1. Strenuous activities

2. Heavy lifting greater than 5kg

3. Prolonged exposure to sunlight

HOME ENVIRONMENTAL HAZARDS:

a) Restrict smoker

b) Crowded area

3. TREATMENTS/THERAPIES

a) Attending the follow up check up :

• Educate client by adhering maintenance therapy, appropriate diet and having exercise will
reduce likelihood of occurrence and aggravation of disease.

4. HEALTH TEACHING/EDUCATION

PREVENTION/PROMOTION

Health teaching about the disease, exercise and diet

o Ask your provider what kind of diet you should follow. You may be asked to limit or not
eat certain foods. Do not limit your protein intake
o Weigh yourself daily and keep a weight log. If you have a sudden change in weight, call
your provider
 o Cut back on salt:
- Limited canned, dried, packaged, and fast
- Don’t add salt to your food at the table
- Season foods with herbs instead of salt when you cook

5. OPD Visit

Instruct that they need to have a health check up

• Emphasize the importance of adhering to medications and attending follow-up check.

• Encourage patient to adhere to weakly blood pressure monitoring and daily hgt monitoring.

6. Diet and Diet Restriction:

o Low salt low fat

o Low sodium and High in potassium: Help to lower blood pressure
o Foods rich in potassium: tomato, watermelon, banana, apple, raw carrots, leafy
vegetables and potato
o Diabetic diet- low in sugar and carbohydrate, low in purine food.
o Low calories- calorie restriction in individuals with hypertension
o Low fat- Advisable to reduce the fat consumption since hypertension has greater risk of
atherosclerotic. Foods rich in cholesterol are liver, meat organ, egg yolk, lobster, crabs,
and prawns. Recommended: vegetable oil like sunflower and olive oil

7. SPIRITUAL CARE AND PSYCHOLOGICAL OR SEXUAL NEEDS

(/) Spiritual counseling

(/) Grief work

(/) Anger Management

(/) Confession

(/) Family therapy

() Reconciliation of conflicted Relationships

(/) Supportive Counseling

(/) Prayer

(/) Meditation, Reflection, and Spiritual Devotion

(/) Religious rituals

 (/) Religious/ Spiritual Materials

References:

1. Tortora (2011). Principles of Anatomy and Physiology, 14th Edition John Wiley & Sons,
2008.
2. Medical and surgical nursing, 6th edition Ignatavicius Workman
3. Medical-Surgical Nursing, 13th edition Janice L. Hinkle and Kerry H. Cheever
4. Nursing Care Plan, 6th edition Gulanick and Myers
5. Nursing diagnosis handbook, 8th edition Betty J. Ackley and Gail B. Ladwig
6. Understanding Medical Surgical Nursing, Williams and Hopper, 2007
7. https://www.scribd.com/doc/35587639/Drug-Study
8. https://nurseslabs.com