VELEZ COLLEGE

College of Nursing

PPW 4TH FLOOR

A CASE STUDY PRESENTATION ON PATIENT E.M., 64 YEARS OLD MALE DIAGNOSED WITH
DECOMPENSATED LIVER DISEASE AND S/P UMBILICAL HERNIA REPAIR

Submitted by:

BSN 4D
Carilimdiliman, Paul John Y.
Yrauda, Noreen Joyce A.

BSN 2C
Carzano, Mitzcel C.
Cedillo, Francis Jay P.
Mercado, Aya Louese A.
Pacheco, Cinderella L.
Ventura, Richard Alex Y.

Submitted to:
Ms. Loggea Keza Hisoler, RN
Ms. Phoebee Marie Christina Reynes, RN,MN
Ms. Fhinel Cristyl Tumulak, RN
Clinical Instructors

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 INTRODUCTION

HEPATIC ENCEPHALOPATHY

 Hepatic encephalopathy is a syndrome observed in patients with cirrhosis. Hepatic encephalopathy is defined as a spectrum of neuropsychiatric abnormalities in patients with liver dysfunction, after
exclusion of other known brain disease. Hepatic encephalopathy is also described in patients without cirrhosis with either spontaneous or surgically created portosystemic shunts. The development of
hepatic encephalopathy is explained, to some extent, by the effect of neurotoxic substances, which occurs in the setting of cirrhosis and portal hypertension.
 Hepatic encephalopathy is reversible with treatment. This relies on suppressing the production of the toxic substances in the intestine and is most commonly done with the laxative lactulose or with non-
absorbable antibiotics. In addition, the treatment of any underlying condition may improve the symptoms. In particular settings, such as acute liver failure, the onset of encephalopathy may indicate the
need for a liver transplant.
 Encephalopathy is the mandatory clinical feature for diagnosis of acute liver failure. Difficulties in the recognition of the early stages of encephalopathy and distinction from drug-induced and renal
induced alterations of mental state do not detract from the value of this sign as the most powerful clinical indicator of the severity of liver disease. Once encephalopathy develops, the patient is at high
risk for the development of cerebral edema and multi organ failure.
Risk Factors:
 Dehydration
 Eating too much protein
 Electrolyte abnormalities and a decrease in potassium from vomiting, or from treatments such as paracentesis or taking diuretics
 Bleeding from the intestines, stomach, or esophagus,
 Infections
 Kidney problems
 Low oxygen levels in the body
 Shunt placement or complication, and surgery.
Stages of Hepatic Encephalopathy
Stage Clinical Symptoms Clinical Signs and EEG Changes
1 Normal level of consciousness with periods of lethargy and euphoria; reversal of day-night Asterixis, impaired writing and ability to draw line figures; Normal EEG
sleep patterns
2 Increased drowsiness; disorientation; inappropriate behavior; mood swings; agitation Asterixis; fetor hepaticus; Abnormal EEG with generalized slowing

3 Stuporous; difficult to rouse; sleeps most of the time; marked confusion; incoherent speech Asterixis; absence of deep tendon reflexes; flaccidity of extremities; EEG markedly
abnormal
4 Comatose; may not respond to painful stimuli Absence of asterixis; absence of deep tendon reflexes; flaccidity of extremities; EEG
markedly abnormal

Clinical Manifestations:
Symptoms may be mild at first. Family members or caregivers may notice that the patient has:
 Breath with a musty or sweet odor
 Change in sleep patterns
 Changes in thinking
 Confusion that is mild
 Forgetfulness
 Mental fogginess
 Personality or mood changes
 Poor concentration
 Poor judgment
 Worsening of handwriting or loss of other small hand movements
More severe symptoms may include:

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  Abnormal movements or shaking of hands or arms
 Agitation, excitement, or seizures (occur rarely)
 Disorientation
 Drowsiness or confusion
 Inappropriate behavior or severe personality changes
 Slurred speech
 Slowed or sluggish movement
Diagnostic Procedures:
 An elevated blood ammonia level is the classic laboratory abnormality reported in patients with hepatic encephalopathy.
 Classic EEG changes associated with hepatic encephalopathy are high-amplitude low-frequency waves and triphasic waves.
 Computed tomography (CT) and magnetic resonance imaging (MRI) studies of the brain may be important in ruling out intracranial lesions when the diagnosis of hepatic encephalopathy is in question.
Treatment:
 Diet
Protein restriction may be appropriate in some patients immediately following a severe flare of symptoms (ie, episodic hepatic encephalopathy). However, protein restriction is rarely justified in patients
with cirrhosis and persistent hepatic encephalopathy.
 Cathartics
Lactulose appears to inhibit intestinal ammonia production by a number of mechanisms.
 Antibiotics
Neomycin and other antibiotics, such as metronidazole, oral vancomycin, paromomycin, and oral quinolones, are administered in an effort to decrease the colonic concentration of ammoniagenic
bacteria.
 Zinc
Zinc deficiency is common in cirrhosis. Even in patients who are not zinc deficient, zinc administration has the potential to improve hyperammonemia by increasing the activity of ornithine
transcarbamylase, an enzyme in the urea cycle. The subsequent increase in ureagenesis results in the loss of ammonia ions.
 L-carnitine
L-carnitine improved hepatic encephalopathy symptoms in several small studies of patients with cirrhosis.  Whether the medication works by improving blood ammonia levels or whether it works centrally
perhaps by decreasing brain ammonia uptake remains unclear.
Nursing Management:
The approach to the patient with hepatic encephalopathy depends upon the severity of mental status changes and upon the certainty of the diagnosis. General management recommendations include the
following:
 Exclude nonhepatic causes of altered mental function.
 Consider checking an arterial ammonia level in the initial assessment of a hospitalized patient with cirrhosis and with impaired mental function. Ammonia levels have less use in a stable outpatient.
 Precipitants of hepatic encephalopathy, such as metabolic disturbances, gastrointestinal bleeding, infection, and constipation, should be corrected.
 Avoid medications that depress central nervous system function, especially benzodiazepines. Patients with severe agitation and hepatic encephalopathy may receive haloperidol as a sedative. Treating
patients who present with coexisting alcohol withdrawal and hepatic encephalopathy is particularly challenging. These patients may require therapy with benzodiazepines in conjunction with lactulose
and other medical therapies for hepatic encephalopathy.
 Patients with severe encephalopathy (ie, grade 3 or 4) who are at risk for aspiration should undergo prophylactic endotracheal intubation. They are optimally managed in the intensive care unit.

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 UMBILICAL HERNIA

 An umbilical hernia occurs when part of the intestine protrudes through an opening in the abdominal muscles. Umbilical hernias are most common in infants, but they can affect adults as well. In an
infant, an umbilical hernia may be especially evident when the infant cries, causing the baby's bellybutton protrude. This is a classic sign of an umbilical hernia.
 After birth, although the umbilical cord disappears (leaving just the dimpled belly-button scar), the weakness or gap in the muscle may persist. Hernias can occur in this area of weakness at any time from
birth through late adulthood, as the weakness progressively bulges and opens, allowing abdominal contents to protrude through. In addition to navel deformity and an associated bulge, the signs and
symptoms include pain at or near the navel area. The hernia bulge pushes out upon the skin directly at or around the navel, distorting the normal contour and architecture.
 Umbilical hernias often occur in adulthood because of progressive and significant tension on the congenital area of weakness beneath the navel. This develops through the normal stresses and strains of
daily activity.

Risk Factors:
 Overweight
 Pregnancy
 Ascites
 Chronic cough
 Constipation and problems in voiding
 Oversized prostate gland
Clinical Manifestation:
 Soft swelling or bulge near the navel (umbilicus). The bulge may range from less than 1/2 inch to about 2 inches (about 1 to 5 centimeters) in diameter.
 Dull ache in groin or other body area with lifting or straining but without an obvious lump
Diagnostic Procedures:
 Physical Examination
 Ultrasound
 X-ray
Complications:
 Complications can occur when the protruding abdominal tissue becomes trapped (incarcerated) and can no longer be pushed back into the abdominal cavity. This reduces the blood supply to the section
of trapped intestine and can lead to umbilical pain and tissue damage. If the trapped portion of intestine is completely cut off from the blood supply (strangulated hernia), tissue death (gangrene) may
occur. Infection may spread throughout the abdominal cavity, causing a life-threatening situation.
 Adults with umbilical hernia are somewhat more likely to experience incarceration or obstruction of the intestines. Emergency surgery is typically required to treat these complications.
Treatment:
 In general, all hernias should be repaired to avoid the possibility of future intestinal strangulation.
 Some hernias have or develop very large openings in the abdominal wall, and closing the opening is complicated because of their large size.
 The treatment of every hernia is individualized, and a discussion of the risks and benefits of surgical versus nonsurgical management needs to take place between the doctor and patient.
 All acutely irreducible hernias need emergency treatment because of the risk of strangulation.
 An attempt to reduce (push back) the hernia will generally be made, often after giving medicine for pain and muscle relaxation. If unsuccessful, emergency surgery is needed.
Nursing Management:
 Instruct the patient to avoid activities that increase intra-abdominal pressure (lifting, coughing, or straining) that may cause the hernia to increase in size.
 Facilitate wound healing by dressing change and monitoring for signs of infection post-operatively.
 Educate the patient.

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 LIVER CIRRHOSIS

Cirrhosis is a chronic (ongoing, long-term) disease of the liver. It means damage to the normal liver tissue that keeps this important  organ from working as it should. If the damage is not stopped, the liver
gradually loses its ability to carry out its normal functions. This is called liver failure, sometimes referred to as end-stage liver disease.
Causes:
 Chronic alcoholism: Alcohol can poison all living cells, causing liver cells to become inflamed and die.
 Hepatitis: Hepatitis means inflammation of the liver from any cause, but it usually refers to a viral infection of the liver.
 Biliary cirrhosis: If bile ducts become blocked, the bile backs up and can damage the liver. The liver becomes inflamed, starting the long process of cell damage that leads to cirrhosis.
 Autoimmune cirrhosis: In autoimmune hepatitis, the body's immune system attacks the liver, causing cell damage that leads to cirrhosis.
 Nonalcoholic fatty liver:This is a condition in which fat builds up in the liver, eventually causing scar tissue to form.
 Inherited diseases: A variety of genetic diseases can damage the liver.
 Drugs, toxins, and infections: Various substances and germs can cause damage to the liver.
 Cardiac cirrhosis: When the heart doesn't pump well, blood "backs up" into the liver.
Clinical Manifestations:
Symptoms are caused by either of 2 problems:
 Gradual failure of the liver to carry out its natural functions
 Distortion of the liver's usual shape and size because of scarring
The most common symptoms of cirrhosis are as follows:
 Tiredness (fatigue) or even exhaustion
 Weakness
 Nausea
 Loss of appetite leading to weight loss
 Loss of sex drive
Symptoms may not appear until complications of cirrhosis set in. Many people do not know they have cirrhosis until they have a complication.
 Jaundice 
 Fever
 Vomiting
 Diarrhea
 Itching 
 Abdominal pain 
 Abdominal swelling or bloating
 Weight gain
 Swelling in ankles and legs (edema)
 Difficulty breathing
 Sensitivity to medications
 Confusion, delirium, personality changes, or hallucinations (encephalopathy)
 Extreme sleepiness, difficulty awakening, or coma 
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  Bleeding from gums or nose 
 Easy bruising
 Blood in vomit or feces 
 Hemorrhoids 
 Loss of muscle mass (wasting)
 In women, abnormal menstrual periods
 In men, enlargement of the breasts (gynecomastia), scrotal swelling, or small testes 
Diagnostic Procedures:
 Blood tests 
 Ultrasound, CT scan, or radioisotope scan
 Laparoscope 
 Liver biopsy
Complications:
 Portal hypertension
 Ascites
 Hepatic encephalopathy
 Clotting disorders
 Itching
Treatment:
 Many medicines have been studied, such as steroids, penicillamine (Cuprimine, Depen), and an anti-inflammatory agent (colchicine), but they have not been shown to prolong survival or improve survival
rate.
 Beta-blocker to lower the pressure in the blood vessels.
 Diuretics to remove extra fluid from your body.
 Adequate protein intake and vitamin supplements can help to correct clotting disorders.
Nursing Responsibilities:
 Stop drinking alcohol to slow the disease process.
 Avoid medications that may be harmful to the liver, such as acetaminophen (Tylenol), or to the kidneys, such asibuprofen (Advil, etc).
 Cut down on salt if problems with fluid retention are present. A low-sodium diet helps relieve that problem.
 Eat a balanced diet with adequate calories and protein.
 Decrease protein intake if hepatic encephalopathy is present.

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 ANATOMY AND PHYSIOLOGY

Hepatobiliary system
-This refers to the liver, gall bladder and bile ducts, and how they work together to make bile. Bile consists of water, electrolytes, bile acids, cholesterol, phospholipids and conjugated bilirubin. Some components
are synthesised by liver cells, the rest are extracted from the blood by the liver.
Liver-  located behind the lower right ribs. The organ is connected by ligaments to the diaphragm on its upper section, and on the left, to the stomach. The liver receives approximately 3-4 pints of blood every
minute. Unlike other organs, which receive blood via only one artery, the liver receives blood from an artery (hepatic artery) and also a vein (portal vein). The liver has three primary sections, or lobes: right, left,
and caudate. The right lobe is the largest lobe-accounting for approximately 3/5 th-2/3rd of the liver size.
-is also a storehouse for vitamins (such as vitamins A, D, E and K), minerals, and glycogen. Glycogen is converted into glucose by the liver, enabling the body to handle the call for quick bursts of energy. It
stores iron, and helps transport fat stores as well.
-Unlike any other organ in the body, a damaged liver can regenerate itself (as in the Promethean Greek legend), provided that there is no cirrhosis- an accumulation of scar tissue. The liver's ability to grow
back is what enables surgeons to remove tumor-containing sections of the organ or to take a healthy section of the liver from a living donor for transplant. Several weeks after surgery, the liver grows back to its
original size, but not its original shape.
Gall bladder- is a pear-shaped sac, which stores the bile produced by the liver. The bile passes through a series of bile ducts, or passageways (similar to the drainage system in and out of a house), known
collectively as the biliary tree. The bile continues its journey into the gallbladder, where it is stored in between the meals. When food enters the intestine, the gallbladder contracts and releases bile into the
small intestine. There, the bile mixes with the food and further aids in digestion, especially of fatty foods.
Although not considered part of the hepatobiliary system, the location and function of the pancreas is closely associated with the bile producing and storing organs. The pancreas is a small organ located behind
the stomach. .The bile duct travels through the pancreas immediately before it enters the small intestine. Thus any problem in the pancreas (such as cancer, pancreatitis and cysts) that is adjacent to the bile
duct often causes blockage of the bile duct and jaundice. Another function of the pancreas, performed by its exocrine gland,is to secrete pancreatic “juice” that also aids in the digestive process. Like bile,
pancreatic juice is transported by ducts. Both the common bile duct and the pancreatic duct empty into the duodenum, part of the small intestine.

Bile is then secreted by the liver into small ducts that join to form the  common hepatic duct. Between meals, secreted bile is stored in the gall bladder, where 80%-90% of the water and electrolytes can be
absorbed, leaving the bile acids and cholesterol. During a meal, the smooth muscles in the gallbladder wall contract, leading to the bile being secreted into the duodenum.

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 CLIENT IN CONTEXT PRESENT STATE INTERVENTIONS EVALUATION
E.M., 64 years old, male, Filipino, married, DOCTOR’S ORDER
residing in Maslog, Danao, born on September General Measurements: January 31,2012
24, 1948 in Danao City, was admitted for the @8:35am
second time in Cebu Velez General Hospital Height: 152.4 cm  IVF to 10gtts/min
under the services of with a case Weight: 57 kgs
number of and hospital number of Abdominal girth: 98 cm @9:30am
. Mid-arm circumference: 23 cm  Remove NGT
IBW: 47.16  May have full diet with strict aspiration
PAST HEALTH HISTORY BMI: 24.6 precautions
Patient is not known hypertensive nor  D/C CBG monitoring
diabetic nor asthmatic and has no known food BMI Categories:  Remove FBC refer if unable to void after 6
and drug allergies. He had no problems at birth, Underweight: <18.5 hours
no childhood diseases or accidents, no serious Normal: 18.5-24.9  Shift (1) omeprazole IV to 400/ tab 1 tab
or chronic illnesses. No known food and drug Overweight: 25-25-29.9 OD PO AC BT
allergies. Immunizations were unrecalled. He Obese: 30 or greater  (2) Unacyn IV to 750mg/tab 1 tab BID PO PC
was diagnosed with right inguinal hernia 10  Lactulose 20cc BID PO
years ago. He was hospitalized last January12,  IVF rate to 20gtts/min
2012 and was diagnosed with liver cirrhosis. He Day 1  I/O in absolute figure
was discharged with improved health and was Date performed: January 31, 2012, Tuesday
given a take home medication, Propanolol General Appearance: Examined sitting on bed afebrile, @10:05am
(Inderal) 40 mg/tab OD. Medication was taken conscious, coherent, and responsive, with PNSS 1L bottle  IVTT with PNSS iiiL @ 20gtts/min
with good compliance. HFD include 6 @30 gtts/min @ L hand infusing well with the following
hypertension and cardiac problems on maternal v/s: BP=140/60 mmHg, PR=90bpm, RR=26cpm, T=36.3 February 1,2012
side and diabetes on paternal side. C/axilla @6:20am
 IVTT with PNSS iiL @ 20 gtts/min
HISTORY OF PRESENT ILLNESS Skin: evenly colored skintone, dry, warm to touch with
3 months PTA, patient had an onset of senile skin turgor; no edema noted has thin calluses on @8:50am
productive cough with whitish to yellowish plantar surface of the feet and palmar surface of the  Ambraxol 25mg/cup 1 cup OD PO
sputum. No difficulty of breathing was hands noted upon palpation.  Shift IV to D5 0.3% NaCl iL @30 gtts/min
reported. No consult sought. Condition was  Limit oral fluids to 1L/day
tolerated. Nails: fingernails are pale not well trimmed with slight  For chest X-ray PA view
10 days PTA, there was onset of dirt on the edges, nails are square, smooth firmly  Nebulizer with Salbutamol neb, 1 neb q 12
abdominal distention and feeling of bloatedness attached to nailplate, no clubbing upon Schamroth hrs
which was not associated with gnawing technique; Toenails are slightly long with minimal dirt,  Report CBC
abdominal pain with a pain scale of 5/10 (1 as nails are slightly pale with CRT=2 secs on all peripheries
the lowest pain and 10 as the worst, aggravated
by pressure and minimized by rest and Head: head is symmetrical and round, hard in consistency
immobilization, an episode of vomiting of upon palpation without involuntary movements; mouth
previously ingested food amounting to 120ml, opens slightly during speech and closes fully; no masses
fever of undocumented temperature. There was noted upon palpation
no change in bowel movements. No consult was
done and no medications were taken. Hair and Scalp: hair is black with distinct gray hairs;
7 days PTA, patient still experienced scalp is white with sparse dandruff noted; no
the same signs and symptoms but had an onset parasites/lice infestations noted; no lesions or swellings

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of loss of appetite. Patient was noted to be
weak and was abnormally sleepy. Still, no
consult was done and no medications were
taken.
5 days PTA, symptoms persisted but
there was no episode of vomiting. Patient was
noted to be frequently wandering around the
house and does not respond when asked
questions such as if he wants to eat or if he was
looking for something. Patient was still noted to
sleep more than usual.
3 days PTA, patient had 3 episodes of
vomiting of previously ingested food amounting
to approximately 240 ml per episode, still
associated with abdominal pain with pain scale
of 5/10 and fever of undocumented
temperature, and with the onset of nausea.
Night PTA, condition persisted which
was associated with colicky pain from the
epigastric area radiating down to the umbilicus
with a pain scale of 10/10. Umbilicus was noted
to be bulging and turns blue upon coughing.
Patient had difficulty passing out stool and
flatus. Consult was done at Danao Hospital.
Patient was given Ketorolac 1 amp IVTT and
Hyoscine 1 amp IVTT which provided slight
relief. Patient was referred to Cebu Velez
General Hospital and was trasported via
ambulance accompanied by his son and his
daughter.
Health Perception and Health Management
Pattern
Patient described health as "wa'y sakit
sa kalawasan". His immediate health concern
was his liver disease and thus stopped drinking
after being diagnosed with the disease. He
rated health 4/10. His perception of his present
state of health is "gi kapoy ko". He was a
moderate smoker 6 years ago, smoking less than
10 sticks per day. He was an alcoholic-beverage
drinker from the age of 14 up to 6 years ago,
drinking 5-7 250 ml bottles (San Miguel,
Tanduay, Tuba) at approximately 5 times a
month. No illicit drug use. SO cannot recall
maintenance medications of the patien but
claimed that they were taken with good
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noted upon palpation; no palpable mass noted
Neck: supple, symmetric with head centrally-located; no
signs of bulging, masses, no swelling, tenderness noted
Eyes: eyeballs symmetrically aligned in sockets without
protruding or shrinking; eyebrows same as hair color,
symmetric and is evenly distributed; lashes short, evenly
shaped, curled outward, both eyes move in a smooth and
coordinated manner in all 6 directions for Cardinal gaze
test, palpebral conjunctiva is pale in color; sclera in both
eyes are slightly icteric; with tiny vessels, lesions not
noted; lacrimal gland non-swelling, no redness, drainage
not noted when nasolacrimal duct palpated (+) PERRLA.
Patient was able to read student’s nameplate @1 feet
distance; normal peripheral vision
Ears: equal in size bilaterally; pinna is in line with the
outer canthus with the eye; no swelling; pinna is non-
tender upon palpation discharges not noted; small amount
of slightly wet foul odor yellow-orange cerumen noted on
both external ear canal; able to repeat the word “ball
pen” @2 feet distance on whisper test
Nose and Sinuses: color same as face, smooth
symmetric, intact nasal septum; perforations not noted;
no obstruction of air flow; purulent discharges not noted,
frontal and maxillary sinus (-) transillumination, non
tender upon palpation
Mouth and Throat: lips are dry without lesion or swelling
noted; dental caries noted on R portion of both upper and
lower 2nd molar teeth of the mouth, missing teeth noted
on the L and R portion of both upper and lower 1st and 3rd
molar teeth of the mouth; tongue is pink, moist, without
lesion, nodule or ulcers; oral mucosa is dry; frenulum is
midline, hard palate is pale with firm, transverse rugae;
uvula hangs freely in the midline, no redness or exudates
noted, foul odor noted; tonsils are pink, symmetric,
enlarged to 1+
Thorax and lungs: RR=26 cpm; uses accessory muscles ,
scapulae are symmetric and non protruding, no crepitus,
tenderness and pain noted, temperature is equal
bilaterally; skin is free of lesion and mass; ration of
anteroposterior diameter to transverse diameter is 1:2,
sternum is at midline and straight; fremitus is symmetric
 compliance as verbalized by “sige man siya
tumar ato kada adlaw”. No use of herbal
medicine. He also seeks "hilot".
House is made of wood, steel and
concrete. House is 2-storey high and is in good
condition; has four rooms (two bedrooms).
Kitchen, dining room, living room and bathroom
are distinct and separate. Toilet is flush type,
electricity supplied by CEVECO. Drinking water
is mineral water and source of water for other
purposes is MCWD. Pitchers and bottles are used
for storing drinking water. Garbage disposal is
by garbage collection at night. Surroundings are
cleaned everyday. Stairs are sturdy, does not
creak and has no breaks. Crowding index is 1.
Distance from the main road is 500 m.
The nearest market place and drug store is
1km. Health center is 1km away. Means of
transportation include tricycle jeepney, van,
and bus. A clean and dry plastic container is
used for storing medications. Cleaning supplies
are kept in a cabinet and a broom is placed in
a corner. Toxic substances are stored in a
cabinet. No surrounding factories. Natural
calamities in the neighborhood include storms,
earthquakes, floods and heavy rains.
Neighborhood is peaceful and orderly.
Last laboratory examinations were
taken upon admission and during
hospitalization.
NUTRITIONAL-METABOLIC PATTERN
Patient's current weight is ; height is. Weight 3
months ago was unrecalled and undocumented.
He is not conscious of his weight. SO claimed
that the patient had lost weight. His appetite
before the onset of the condition was good.
Upon the onset of the condition, appetite
deteriorated. He can hardly consume his meal.
Upon hospitalization, SO expressed that
patient’s appetite was better than before
hospitalization. Diet during hospitalization is
the same as usual diet at home but was advised
to avoid fatty foods. SO cannot recall the
vitamins and dietary supplements taken by the
patient. Patient had no known food and drug
allergies. He has no food preference and eats
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and easily identified in the upper region of the lungs.
Breast: breasts are bilaterally everted, brown color;
dimpling and retraction not noted; Lesions, lumps,
swellings, discharges not noted; gynecomastia noted
Heart, peripheral vessels and extremities: Carotid
pulses bilaterally equal + 2, bruits not noted upon
auscultation; thrills, pulsations, heaves, lifts not noted;
heart sounds, murmurs, clicks not noted upon
auscultation. Lower extremities warm to touch
bilaterally, varicosities not noted and (-) edema.
Temporal, brachial, radial, and dorsalispedis pulses
strong, elastic bilaterally, +2.
Abdomen: is protuberant; skin is is slightly lighter
compare to extremities; no striae and rashes noted;
tenderness noted on the epigastric region upon palpation;
with 6 inches dry vertical incision on the umbilical region
of the abdomen noted; abdominal girth= 98cm;
Genito-urinary: grossly male, no discharges, swelling or
rashes noted as verbalized, with FBC-CDU.
Musculoskeletal: assisted walking; upper and lower
extremities symmetric, lesions nodules, deformities,
tenderness, swelling not noted; full ROM
5/5 5/5
5/5 5/5
Scale for grading muscle strength:
5- active motion against full resistance
4- active motion against some resistance
3- active motion against gravity
2- passive ROM
1- slight flicker of contraction
0- no muscular contraction
Neurologic Assessment
Mental Status: Patient was responsive and conscious. Px
 what is served to him. was able to follow and perform instructions properly;
24-Hour Diet Recall (as recalled by the SO) oriented to person (able to recognize his daughter and his
24 Hour Usual diet son), place (able to identify that he is in Cebu Velez
Recall General Hospital), and time (able to recognize time:
Breakfast 1 cup of rice; 1 cup of rice, afternoon). For the remote memory: px wasn’t able to
egg; fish; 1 egg, milk recall the exact date of their wedding day (November).
cup of milk
Lunch 1 cup of rice; 1 cup of ice, Motor/ Cerebellar function: Full ROM on both upper and
beef steak; 1 sabaw, lower extremities, (+) finger-nose test, (+) fingers to
glass of water adobo, thumb test, needs assistance in standing and walking.
seafood, 1
cup milk or 1 5/5 5/5
glass soft
drink
5/5 5/5
Dinner 1 cup of rice; 1 cup of rice,
beef steak; sabaw, meat,
vegetables; 1 1 cup milk or
glass of water 1 glass of soft Sensory function: Patient was able to recognize light
drink touch with the use of a cotton stroked vertically on the
face and able to feel pain when slightly pinched on both
Snacks Bread; 1 glass Bread and upper and lower extremities.
of water coffee, milk
or softdrink
Cranial Nerves Assessment
Patient used to drink alcoholic beverages when I (Olfactory): can distinguish scent of alcohol with eyes
stressed. There are 7 people at home. Son closed
shops for food cooks and prepares meals. Food
is stored in cabinets and the refrigerator. II (Optic): px can read student’s nameplate at 2 ft.
Patient was not able to name the basic food distance
groups but was able to give examples of foods
high in caloric content such as adobo, humba III, IV, VI (Occulomotor, Trochlear, Abducens) able to
and lechon. Foods with low nutritional value are follow 6 cardinal gaze and pupils are equally round and
junk food and softdrinks. SO said that patient reactive to light accommodation, with normal peripheral
can improve his diet by eating more vegetables vision, can blink eyes, can close and open mouth, can
and fruits. clench teeth, can feel when face is touched, can
distinguish sharp from dull using a ball pen.
ELIMINATION PATTERN
Patient usually voids 3 to 4 times during the day V (Trigeminal): can feel touch of finger on forehead, chin,
and 1 to 2 times at night. Voids approximately and cheeks, can clench teeth.
240 ml of clear, yellow, non-foul smelling urine
before onset of illness. Patient usually drinks VII (Facial): intact light touch sensation, can smile, can
approximately 1 to 2 liters of water per day and raise eyebrows, can wrinkle forehead
usually drinks coffee in the morning. Usual
number of bowel movements is 1 to 2 times per VIII: Vestibulocochlear: can hear the word “ball pen” at
day. Stool semi-solid. Usual timing of bowel 2ft distance.
movement is after lunch and dinner. Patient
11 | P a g e
 does not postpone defecation. Defined diarrhea
as "basa ug tae" and constipation as "mag lisod
ug kalibang". Patient had no problems with
bowel and bladder movement before
hospitalization. On the night prior to admission,
patient had difficulty in passing out stool and
flatus.
Upon hospitalization, patient was catheterized.
Amount of urine drained per shift ranged from
300-500ml, yellow-amber in color.
ACTIVITY-EXERCISE PATTERN
Patient is a retired utility worker. Activities at
work such as heavy lifting, walking and running
serve as "exercise" for the patient. Before the
onset of present condition, he was an active
person. Patients typical day is waking up at 5
am, taking a bath, eating breakfast, going to
work and going home at night. Eat dinner while
watching T.V., bathe, if there's a special
occassion: drink and after which, sleep at 10 or
11 pm. He did not have problems regarding his
ADL’s.
Upon the onset on illness and during
hospitalization, he cannot perform ADL’s such
as bathing, dressing, eating, and grooming
without assistance. He was also noted to be
weak and tired.
COGNITIVE-PERCEPTUAL PATTERN
Patient speaks bisaya and understands simple
english and tagalog. Patient is an elementary
graduate. Patient perceives illness as "nasakit,
makakapoy sa lawas, kailangan magpatambal"
and see treatments as "mga tambal, makapa-
ayo sa sakit sa lawas". He was unable to recall
the date of his wedding and was unable to
recall his son’s birthday. When asked about his
last meal, he did not answer.
Patient does no wear eyeglasses. Patient did
not have any eye and ear examinations but said
that he cannot see clearly anymore. Px does not
make use of eye wear and hearing aids; had no
problems with headaches, vertigo and dizziness.
He experienced dizziness, headache, nausea
and vomiting during episodes of alcohol
12 | P a g e
IX, X (Glossopharyngeal, vagus): (+) gag reflex: able to
swallow own saliva
XI: Spinal Accessory: can shrug and move shoulder
XII: Hypoglossal: able to protrude his tongue, no
fasciculation
Day 2
February 1, 2011 10 am(Wednesday)
General appearance:
Examined lying on bed, awake, conscious, responsive,
with PNSS 1L bottle 7 @30gtts/min infusing well @L hand
with the following v/s: BP=130/80mmHg, PR=98bpm,
RR=30cpm, T=37.4C/axilla
Skin: with thin calluses on both palmar and plantar
surfaces noted upon palapation
Eyes: palpebral conjunctiva is pale in color; sclera in both
eyes are slightly icteric
Thorax and lungs: RR=30 cpm; uses accessory muscles.
Breasts: gynecomastia noted
Abdomen: protuberant; with 6 inches dry vertical incision
on the umbilical region of the abdomen noted; abdominal
girth= 98cm
Neurologic Assessment:
Mental Status: Patient was responsive and conscious but
was incoherent (when ask of how he was feeling, the px
just uttered incomprehensible words). Px had decreased
LOC and was lethargic during examination. Patient can’t
follow simple instructions like raising hands
 intoxication.
SLEEP-REST PATTERN
Patient usually sleeps at 10 or 11 pm and wakes
up at 5 am. Sleeping time is approximately 6 to
7 hours. Patient takes afternoon naps when he
has time to do so. He sleeps well but when
suddenly awakened, patient has a hard time
going back to sleep. His usual routine before
retiring is grooming, hygiene. Bedroom has 1
bed, cabinets, closet, mirror, shoe rack. Patient
sleeps with 2 pillows, one on the head and one
between the legs. Patient snores but minimally.
Upon the onset of the disease, patient was
reported to have slept longer than normal. He
also tend to take long naps in the afternoon.
During hospitalization, patient is noted to be
always tired and frequently sleeps. Sometimes,
he doesn’t respond to the questions raised by
the nurse.
Motor/ Cerebellar function needs assistance in standing
and walking
Day 3
February 2, 2011 10 am(Thursday)
General appearance:
Examined lying on bed, awake, conscious, responsive,
with D5.3 NaCl 1L bottle 8 @20gtts/min infusing well @L
hand with the following v/s: BP=130/70mmHg, PR=98bpm,
RR=36cpm, T=37.3C/axilla
Skin: with thin calluses on both palmar and plantar
surfaces noted upon palapation
Eyes: palpebral conjunctiva is pale in color; sclera in both
eyes are slightly icteric

SELF-PERCEPTION AND SELF-CONCEPT

Patient identifies self as a heterosexual male. Mouth and pharynx: dry oral mucosa
His weakness is his present condition and his
strengths are his family, friends and God. He is
satisfied with his self, is okay with his body Thorax and lungs: RR=36 cpm; uses accessory muscles ,
image; others describe him as a happy, good
and hardworking person. Patient does not mind Breasts: gynecomastia noted
body-image-effects of the incision on his
abdomen. Abdomen: protuberant; with 6 inches dry vertical
incision on the epigastric region of the abdomen noted;
Using the Rosenberg's Self-Esteem Scale,
patient scored a 22 which is within the normal abdominal girth= 98cm;
range.
Musculoskeletal: full ROM
ROLE-RELATIONSHIP PATTERN
Patient’s roles inclue father, husband, son, 4/5 4/5
friend. When asked whether he feels any
pressure or problems about his roles, he shook
4/5 4/5
his head. Health status did not alter
relationship with other people. He lives with his
family which consists of him, his wife, his son,
son's wife and his son's four children. Decisions
Scale for grading muscle strength:
are made together with the family. No
problems in communication, parenting, 5- active motion against full resistance
4- active motion against some resistance
relatives, abuse, marital concerns and
discipline. No reported conflicts with his 3- active motion against gravity
2- passive ROM
relatives and friends.

13 | P a g e
 1- slight flicker of contraction
(See appendix for Genogram and Ecomap) 0- no muscular contraction

SEXUALITY-REPRODUCTIVE PATTERN Neurologic Assessment

Sexual orientation is male. First sexual contact
was at the age of 19. He has his ex-girlfriend Mental Status: Patient was responsive and conscious.
and his wife as his only sexual partners. Patient Patient was able to answer appropriately when asked how
has already forgotten the date he was many glasses of water he had taken and was able to ask
circumcised but claimed to be circumcised in a the student nurse about his blood pressure.
traditional way. Last sexual contact was
unrecalled but has no reported experiences of
problems regarding sexual activities. No use of
contraceptives were reported. He does not
perform TSE.

COPING STRESS-TOLERANCE PATTERN Motor/ Cerebellar function: needs assistance in standing

Patient defined stress as "trabaho", "makaluya". and walking.
Major stressor at present is his condition.
Coping strategies when stressed are: talking to
others, trying to forget, do something, pray, go
to sleep and seek help from family. He used to
resort to drinking alcohol when he has problems 4/5 4/5
or if he’s under stress but has already stopped
doing so. He relies on family for help. Problems 4/5 4/5
are usually solved with the help of each
member of the family.

VALUE-BELIEF PATTERN
Patient is a Roman Catholic. He and family
prays the rosary, attends Sunday masses and BLOOD CHEMISTRY
participates in religious events like processions PURPOSE: Creatinine test is used to assess renal
and feast days. His family does not practice any glomerular filtration and screen for renal damage.
superstitious belief. SO claimed that his father Urea/BUN is used to assess renal perfusion. Liver function
has strong faith in God. test assesses hepatic involvement of a disease.
Test Result Ref. Range
Implication: Creatinine and 1/28/12@
uric acid are in normal 02:44 0.9 0.6-1.5
range. Creatinine
January 29,2012 @ 14:14 1/29/12@ 1.0 0.6-1.5
Liver Function Test 14:14
Purpose: Purpose: Liver Creatinine
enzyme test are performed
at the same time to confirm
liver disorder. Liver function tests done individually do
not give the physician very much information, but used in
combination with a careful history, physical examination,

14 | P a g e
Test Result Ref. Range

SGPT/ALT 29 U/L 0-45

and imaging studies, they contribute to making an
accurate diagnosis of the specific liver disorder.

Implication: within normal range.

COMPLETE BLOOD COUNT

Purpose: A complete blood count serves a clinical
purpose, through which it serves by diagnosing certain
diseases and evaluates the stage of a particular disease.
The cells that generally circulate the body are divided
into three and are counted, and thus give a general health
status about the client.

CBC 1/28/12@ 1/29/12 @ Normal Range

2:14 5:46

WBC 10.00 6.59 4.1-10.9 k/µL

7.05 4.60 2.5-7.5 k/µL;
NEU 80.8 77.3 47.0-80.0 %
1.32 .919 1.0-4.0 k/µL;
LYM 15.1 15.5 13.0-40.0 %
.232 .322 0.1-1.2 k/µL;
MONO 2.66 5.59 2.0-11.0 %
.121 .049 0.0-0.5 k/µL;
EOS 1.38 .821 0.0-5.0 %
.001 .046 0.0-0.10 k/µL;
BASO .015 .777 0.0-2.0 %

RBC 4.25 4.37 4.5-5.9 M/µL

HGB 13.4 13.8 13.5-17.5 g/dL

HCT 40.4 40.8 41.0-53.0 %

MCV 95.0 93.4 80.0-100.0 fL

MCH 31.4 31.5 26.0-34.0 pg

MCHC 33.0 33.8 31.0

36.0 g/dL

15 | P a g e
 RDW 15.5 16.6 11.6-18.0 %

PLT 184 168 140.0-440.0

k/µL

MPV 8.23 9.07

 Low RBC, HGB, and HCT may result from hepatic

insufficiency (liver cirrhosis) leading to
congestion of splenic vessels thus leading to
splenomegaly resulting to anemia,
thrombocytopnenia and hemorrhage
 Decrease LYM may result from splenomegaly and
spleen retains the ability to produce lymphocytes
and, as such, remains an hematopoietic organ.
 Increase NEU levels may implicate acute
bacterial infection and low indicates an
increased

January 28,2012 @ 2:45am

PROTHROMBIN TIME (N.V. = 9.5-12 sec.)
Purpose: Prothrombin time test or PT test evaluates the
ability of blood to clot properly; it can be used to help
diagnose bleeding.
Prothrombin Time Result
Control (92% Activity) 11.3 sec
Client 13.3 sec
% Activity 69.2% INR = 1.2
(N=2.0-3.0
Implication: Increased Prothrombin Time results from the
decrease in Vitamin K synthesis due to compromised liver
function thus leading to an increase in clotting time that
increases the risk for bleeding.

Bleeding time:
Purpose: The test helps identify people who have defects
in their platelet function. This is the ability of blood to
clot following a wound or trauma. The bleeding time test
is usually used on patients who have a history of
prolonged bleeding after cuts, or who have a family
history of bleeding disorders. Also, the bleeding time test
is sometimes performed as a preoperative test to
determine a patient's likely bleeding response during and
after surgery.

16 | P a g e
 Result: 1 min. and 20 sec. (N.V.= 1-3 mins.)
Implication: normal findings

Clotting time
Purpose:is to check the time required for blood to clot in
a glass tube; a measure of the intrinsic system of
coagulation.
Result: 2 mins. and 33 sec. (N.V.=2-6 mins)
Implication: normal findings

Activated Partial Thromboplastin

Purpose: to check the period required for clot formation
in recalcified blood plasma after contact activation and
the addition of platelet substitutes; used to address the
intrinsic and common pathways of coagulation.
Result: Time=42.9 sec (N.V= 25-39 sec)
Implication: prolonged aPTT may be caused by Liver
disease due to:
- Malabsorption of vitamin K [a fat soluble vitamin] and
which leads to decreased gamma carboxylation of the
vitamin K dependent clotting factors
- Decreased synthesis of clotting factors

Urinalysis Report 1/29/12 22 @ 22:44:18

Purpose: One of the most useful indicators of health and
disease, helpful in detection of renal or metabolic
disorders, an aid in diagnosing and following the course of
treatment in diseases of the kidney and urinary system
and in detecting disorders in other parts of the body such
as metabolic or endocrine abnormalities in which the
kidneys function normally.

Macroscopic
Result Referen Unit
ce
Range
Color yellow Light Y,
Dark Y
Clarity Slightly Clear
cloudy
Chemical Test
pH 5.0 5.0-8.0
Specific 1.035 1.001-
Gravity 1.035
Protein + <10 mg/dL
Glucose - - mg/dL

17 | P a g e
 Ketone - - mg/dL
Urobilinogen normal - mg/dL
Blood + -
Bilirubin - - mg/dL
Nitrite - -
Ascorbic acid + mg/dL

Microscopic
Result Referenc Unit
e Range
RBC 2 0-3/hpf
WBC 5 0-5/hpf
Bacteria MOD none
Mucus rare none
Thread
Hyaline 20/lpf
Cast

Implication: normal findings

KEY ISSUES
Date Identified: January 31, 2012
1. Ineffective Breathing Pattern r/t decreased lung
capacity as manifested by RR= 26cpm and use of
accessory muscles noted

Independent Interventions: Desired Outcome:

Scientific Basis:
Also known as rapid breathing, tachypnea is common in
people who have airway obstruction or weak lungs, either
because they are not getting enough oxygen or they are
trying to "blow off" excess carbon dioxide (a waste
product of metabolism) which has built up in their blood
due to inadequate expulsion of inhaled air.
Source:
http://copd.about.com/od/glossaryofcopdterms/g/tachy
pnea.htm
1. Assessed respiratory rate, rhythm, and depth
R: Respiratory rate and rhythm changes are early
warning signs of impending respiratory difficulties
2. Assess skin color and temperature
R: Cyanosis occurs when at least 5g of hemoglobin
is desaturated. Cool pale skin may be secondary to
a compensatory/vasoconstictive response to
hypoxemia
3. Assessed for presence of cough and secretions.
R: Indicates possible airway obstruction
4. Auscultated chest
R: To evaluate presence and character of
adventitious breath sounds.
5. Assessed for presence of pain or discomfort.
R: May restrict or limit respiratory effort
Within the course of nursing interventions,
the patient will be able to establish an
effective respiratory pattern as evidenced by
absence of cyanosis and other signs and
symptoms of hypoxia
Actual Outcome:
After 2 days of nursing interventions,
patient’s RR was still above normal range
(36cpm). Use of accessory mucles still noted.

18 | P a g e
 6.  Positioned patient with proper body alignment
for optimal breathing pattern
R: If not contraindicated, a sitting position allows
for good lung excursion and chest expansion
7. Encouraged slower and deeper respirations
through the use of pursed-lips technique.
R: To assist client in “taking control” of respiration
8. Maintained calm attitude while dealing with the
patient and SO
R: To limit level of anxiety
9. Noted emotional responses.
R: Anxiety may be causing acute or chronic
hyperventilation.
10. Encouraged adequate rest periods between
activities
R: To limit fatigue.

Date Identified: February 1, 2012

2. Ineffective Cerebral Tissue Perfusion r/t interruption
of blood flow secondary to accumulation of toxic
substances in the brain in hepatic encephalopathy as
manifested by altered mental status and
incomprehensible speech
Scientific Basis:
Hepatic encephalopathy is a worsening of brain function
that occurs when the liver is no longer able to remove
toxic substances in the blood.
Ammonia, which is produced by the body when proteins
are digested, is one of the harmful substances that is
normally made harmless by the liver. Many other
substances may also build up in the body if the liver is not
working well. They can cause damage to the nervous
system.
Source:
http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH000134
Independent Interventions:
1. Determined presence of visual, sensory and motor
changes, altered mental status and personality
changes.
R: Deterioration in neurological signs and symptoms
may reflect decreased intracranial adaptive
capacity.
2. Monitored neurological status frequently
R: Identifies trends in LOC and is useful in
determining location, extent, and progression or
resolution.
3. Assessed higher function such as speech
R: Changes in cognition and speech content are
indicators of location and degree of cerebral
involvement.
4. Elevated HOB and maintained head in midline or
neutral position
R: To promote circulation and venous return
5. Perform passive range-of-motion exercises
R:  Promotes collateral circulation.
6. Monitored intake and output.
R: to prevent volume overload or deficit.
7. Provide rest periods between activities.
Desired Outcome:
Within the course of nursing interventions,
the patient will be able to maintain or
impove LOC, cognition, motor and sensory
function and display no further deterioration
or recurrence of deficits
Actual Outcome:
February 1, 2012
After 1 day of nursing interventions,
improved cognition was noted. Patient was
noted to be coherent and oriented to the
time of the day. No dizziness and headache
reported. Neuromuscular weakness still
present.

19 | P a g e
 Date Identified: January 31, 2012
3. Impaired Tissue and Skin Integrity r/t physical
immobilization and mechanical interruption of the skin
secondary to S/P umbilical hernia repair as manifested by
6 inches dry vertical incision on the umbilical region of
the abdomen.
Scientific Basis:
One of the possible complications of this approach is that
it can put excessive strain on the surrounding tissues
through which the sutures are passed. Over time, with
normal bodily exertion, this strain can lead to the tearing
of these stressed tissues and the formation of another
hernia. The frequency of such recurrent hernias,
especially in the groin region, has led to the development
of many different methods of suturing the deep tissue
layers in an attempt to provide better results.
Source:
http://www.medicinenet.com/hernia/page2.htm#4howis
20 | P a g e
R: Absolute rest and quite may be needed to
conserve oxygen
Independent Interventions:
1. Assessed blood supply and sensation of affected Desired Outcome:
area. Within the course of nursing interventions,
R:To evaluate actual/potential impairment of the display timely healing of incision without
circulation complication and prevent formation of
2. Determined degree, depth, and damage to pressure ulcers
integumentary system.
R:Facilitates approximation of the extent of
damage
3. Inspect the incision every shift using the REEDA Actual Outcome:
(redness, edema, ecchymosis, discharge and February 1, 2012
approximation) method. After one day of nursing intervention, signs
R: Frequent assessment can detect signs of infection on the incision site such as
and symptoms of possible infection, complications. redness, swelling, and discharges were not
4. Assessed vital signs of the patient provide means noted. Patient maintained body temperature
to stabilize vital signs, such as TSB, etc. (37.4C/axilla) within normal range.
R: An increase in temperature, pulse and blood Formation of pressure ulcers were not noted.
pressure may indicate infection and other
complications.
5. Kept the area clean and dry and supported
incision with abdominal binder
R: To assist the body’s natural process of repair
6. Instructed and assisted the patient with general
hygiene, including hand washing and toilet
practices.
R: Proper hand washing is the most effective
method of disease prevention. Bacteria from hands
can easily contaminate other areas.
7. Instructed to avoid strenuous activities.
R: Shear force or pressure may induce more damage
to the skin and tissues.
8. Helped the patient to assume a comfortable
position.
R:To help reduce tension at the incision site by
relieving pressure to it.
9. Emphasized the importance of proper fit of
clothing
R: Facilitates adequate circulation
10. Emphasized importance of skin and measures to
maintain proper skin functioning
R: The integumentary systemis the largest
 Date Identified: January 31, 2012
4. Altered Body Defenses r/t abnormal blood profile as
manifested by LYM=.919k/ µL; RBC= 4.25 M/µL; HGB= 13.4
g/dl; HCT= 40.4%
Scientific Basis:
Anemia is a condition of lower than normal RBC count and
decreased hemoglobin level in the blood, causing tissue
hypoxia due to deficient oxygen transport and
recruitment of compensatory mechanisms designed to
increase oxygen delivery to the tissues
Source: Pathophysiology.Porth.6th edition, page 276.
Date Identified: January 31, 2012
5. Risk for Bleeding r/t altered hepatic function
secondary to damaged structure and function of liver cells
in liver cirrhosis as manifested by increased in
prothrombin time=13.3 seconds and activated partial
thromboplastin=42.9 seconds
Scientific Basis:
Routine tests of liver function may be quite normal in
cirrhosis. A decreased serum albumin and a prolonged
prothrombin time directly reflect impaired hepatic
21 | P a g e
multifunctional organ of the body.
Independent Interventions:
1. Monitored vital signs ( BP, HR, RR and T)
R: Change in vital signs is a significant indicator for Desired Outcome:
the alteration of the patient’s body defenses. Within the course of nursing intervention,
2. Observed for any dependent or generalized patient will be free from any complication
edema brought about by the condition and be free
R: To note the degree of organ involvement. from signs of infection such as fever,
3. Noted for any changes related to systemic and swelling of the incision site, and pain.
peripheral alterations in circulation.
R: To know the level of impairment or damage.
4. Evaluated signs of infection especially wjen Actual Outcome:
immune system in compromised. February 2, 2012
R: To relieve the symptoms manifested by the After 2 days of nursing intervention, there
patient. were no signs and symptoms of exacerbation
5. Inspected surrounding skin of IV site for signs of and infection noted such as fever, redness,
infection such as redness, swelling and swelling and itchiness. V/S:
inflammation. BP=130/80mmHg, PR=98bpm, RR=30cpm,
R: To assess the extent or involvement of injury. T=37.4C/axilla.
6. Performed hand washing before and after
contact.
R: To prevent the spreading of infection.
7. Kept environment clean and organized.
R: To prevent transmission of microorganisms.
8. Afforded rest and sleep.
R: To promote wellness.
9. Encouraged intake of Vitamin C foods such as
guava, oranges, pineapple and citrus juices and
avoid oily and fatty foods.
R: Aids in boosting immune system and to avoid
further formation of plaques that causes
vasoconstriction and damage to arteries thus
causing further inflammation.
10. Encouraged adequate fluid intake.
R: To aid proper circulation and hydration.
Independent Interventions: Desired Outcome:
1. Observed for presence of petechiae, ecchymosis,
Within the course of nursing interventions,
and bleeding in one or more sites. the patient will be able to maintain
R: Subacute Disseminated Intravascular Coagulation
homeostasis with the absence of bleeding,
may develop secondary to altered clotting factors.
 function in the truest sense. An increased serum gamma
globulin accompanies many forms of chronic liver disease.
AST and ALT are often moderately elevated, while
alkaline phosphatase may be normal or increased,
particularly with biliary obstruction. Bilirubin is usually
normal. Increased total serum globulin is common. A
normochromic normocytic (occasionally macrocytic)
anemia, thrombocytopenia, and leukopenia may be
present. With alcohol-related liver disease, the anemia is
occasionally macrocytic.
Source:
http://www.murrasaca.com/Hepaticirrosis.htm
Date Identified: February 1, 2012
6. Acute Confusion r/t exacerbation of chronic illness
secondary accumulation of toxic substances in the brain in
hepatic encephalopathy as manifested by fluctuations in
cognition and level of consciousness.
2. Assessed for signs and symptoms of GI bleeding. be free from injuries, and demonstrate
R: The GI tract is the most common site of bleeding behaviors that decreases the risk of injury.
due to its mucosal fragility.
3. Monitored vital signs especially BP and pulse. Actual Outcome:
R: Increased pulse rate and decreased BP may February 2,2012
indicate loss of circulating blood volume, requiring After 2 days of nursing interventions, patient
further evaluation. was free from injuries and signs of bleeding
4. Noted changes in mentation and LOC such as ecchymosis, hypotension and dark
R: Changes may indicate decreased cerebral stools.
perfusion secondary to hypovolemia or hypoxemia.
5. Instructed to avoid straining during defecation
and the use of soft-bristle toothbrush.
R: In the presence of clotting factor disturbances,
minimal trauma can cause bleeding.
6. Encouraged oral fluids as tolerated and if not
contraindicated.
R: To help soften the stool thus preventing
straining.
7. Taught proper coughing techniques
R: In the presence of clotting factor disturbances,
minimal trauma can cause bleeding.
8. Monitored Hgb, Hct, platelets and clotting
factors.
R: Indicators of anemia, active bleeding, or
impending complications such as DIC.
9. Advised to avoid aspirin-containing products or
medications.
R: Prolongs coagulation, potentiating the risk for
bleeding

Scientific Basis: Independent Interventions:

When the toxic substances accumulate sufficiently in the
blood, the function of the brain is impaired, a condition
called hepatic encephalopathy. Sleeping during the day
rather than at night (reversal of the normal sleep pattern)
is among the earliest symptoms of hepatic
encephalopathy. Other symptoms include irritability,
inability to concentrate or perform calculations, loss of
memory, confusion, or depressed levels of consciousness.
Ultimately, severe hepatic encephalopathy
causes coma and death.
Source:
http://www.medicinenet.com/cirrhosis/page2.htm
1. Observed for changes in behavior and mentation:
lethargy, confusion, drowsiness, speech and
irritability.
R: Ongoing assessment of mental status and
behavior is important because of fluctuating nature
of hepatic encephalopathy.
2. Assessed diet and nutritional status.
R: To identify possible deficiencies of essential
nutrients and vitamins that could affect mental
status.
3. Reviewed current medication regimen
R: Adverse drug reactions or interactions may
potentiate or exacerbate confusion.
4. Noted development or presence of asterixis, fetor
Desired Outcome:
Within the course of nursing interventions,
the patient will be able to regain or maintain
usual mentation and reality orientation and
be free from injuries.
Actual Outcome:
February 2, 2012
After 1 day of nursing interventions:
Patient was able to ask “pila akong BP day?”,
respond appropriately to questions raised by
the nurse, and was able to tell the time of
the day. No injuries were reported.

22 | P a g e

Date Identified: January 31, 2012
7. Fatigue r/t decreased oxygen supply to the brain and
other parts of the body secondary to impaired blood
circulation in hepatic encephalopathy as manifested by
observable lack of energy and verbalization of “gikapoy
ko”
Cues: RBC= 4.25 M/µL; HGB= 13.4 g/dl; HCT= 40.4%,
Scientific Basis:
Fatigue is a very common complaint and it is important to
remember that it is a symptom and not a disease. Many
illnesses can result in the complaint of fatigue and they
can be physical, psychological, or a combination of the
two.
Source:
http://www.medicinenet.com/fatigue/article.htm
23 | P a g e
hepaticus, and seizure activity.
R: Suggest elevating serum ammonia levels and
increased risk of progression
5. Reoriented to time, place, person and situation
as needed.
R: Assists in maintaining reality orientation,
reducing confusion and anxiety.
6. Maintained a pleasant, quiet environment and
approached in a slow, calm manner.
R: Reduces excessive stimulation and sensory
overload.
7. Encouraged uninterrupted rest periods
R: Promotes relaxation and may enhance coping
8. Reduced provocative stimuli and confrontation
R: Avoids triggering agitated and violent responses;
promotes client safety
9. Provided continuity of care
R: Familiarity provides reassurance and aids in
reducing anxiety.
10. Used simple and short sentences and
instructions. Allowed sufficient time for the client
to respond.
R: To facilitate communication and promote
effective decision making.
Independent Interventions
1. Determined the ability to participate in
activities/level of mobility.
Desired Outcome
R: Fatigue can limit the person’s ability o Within the course of nursing interventions,
participate in self-care and to perform her the patient will report improved sense of
responsibilities. energy, perform ADLs and participate in
2. Assessed presence/degree of sleep disturbances. desired activities at level of tolerance.
R: Changes in the person’s sleep pattern may be a Actual Outcome
contributing factor in the development of fatigue. After 2 days of student nurse-patient
3. Arranged things within the reach of the patient. interaction:
R: To provide an environment conducive to relief of February 1, 2012
fatigue and to prevent physical exhaustion. Patient was able to have adequate rest
4.Assisted with self-care needs; maintained on High periods but still needed assistance in
Fowler’s position performing ADLs such as eating, toileting,
R: To assist client to cope with fatigue and manage sitting up, and changing clothes.
within individual limits of ability
5. Taught the patient how to perform deep February 2, 2012
breathing exercises. Patient’s sense of energy improved a little,

Date Identified: January 31, 2012
8. Disturbed Sleeping Pattern r/t uncomfortable sleep
environment and prolonged discomfort secondary to
chronic illness as manifested by daytime naps, decreased
energy level and SO’s verbalization of “mag-sige man na
siya ug mata-mata kada gabii”.
Scientific Basis:
Hepatic encephalopathy describes the spectrum of
potentially reversible neuropsychiatric abnormalities seen
in patients with liver dysfunction. Disturbance in the
diurnal sleep pattern (insomnia and hypersomnia) is a
common early feature that typically precedes overt
neurologic signs. More advanced neurologic features
include the presence of asterixis, hyperactive deep
tendon reflexes, and less commonly, transient
decerebrate posturing.  4. Supported continuation of usual bedtime rituals
Source:
http://www.murrasaca.com/Hepaticirrosis.htm
Date Identified: January 31, 2012
9. Activity Intolerance r/t imbalance between oxygen
24 | P a g e
R: To provide a way of minimizing fatigue through but still needed assistance in performing
relaxation. ADLs.
6. Reduced environmental stimuli.
R: To promote relaxation and to prevent any
disturbances.
7. Placed care with consistent rest periods between
activities.
R: To conserve energy
8.Taught relaxation techniques such as deep
breathing exercises.
R: To promote comfort
Independent Interventions:
1. Assesses the normal sleeping pattern, rituals and Desired Outcome:
environment of the patient at home. Within the course of nursing interventions,
R: In order for activities and surroundings to be the patient will be able to identify factors
modified based on client usual pattern. that impair sleep and report improvement of
2. Encouraged to do deep breathing exercises. sleep-rest pattern.
R: Deep breathing promotes relaxation and diverts
attention.
3 Suggested abstaining from daytime naps. Actual Outcome:
R: Daytime naps impair ability to sleep at night. After 2 days of nursing interventions:
February 1, 2012
such as taking half-baths before going to sleep. Patient was able to rest and sleep.
R: to promote relaxation and readiness for sleep. Increased energy level noted.
5. Encouraged not to drink a lot of fluids before
bedtime. February 2, 2012
R: to minimize going to the comfort room in the Patient was able to verbalize “mao ra
middle of the night. gihapon, wa ko’y tarong nga tulog”. Patient
6. Recommended quiet activities such as reading or was noted to resort to daytime naps to
imagery or listening of music. regain energy.
R: to reduce stimulation to promote relaxation and
cover up noise if present.
7. Minimized going in and out of room.
R: Allows patient to attain periods of restful sleep.
8. Provided adequate rest periods.
R: To promote rest and to maximize energy.
9. Encouraged patient to restrict caffeine intake and
other stimulating substances.
R: They disrupt sleep patterns
10. Encouraged to drink milk
 supply and demand secondary to impaired blood flow in
hepatic encephalopathy as manifested by generalized
neuromuscular weakness and muscle strength of 4/5 on all
extremities
Scientific Basis:
Diseases of the neuromuscular system,
injuries, metabolic diseases, and toxins can all cause of
measurable muscle weakness.
Source:
http://www.medicinenet.com/weakness/symptoms.htm
Date Identified: January 31, 2012
10. Partial Self-Care Deficit r/t neuromuscular weakness
and mechanical restrictions secondary to accumulation in
the bloodstream of toxic substances that are normally
removed by the liver in hepatic encephalophathy and
umbilical hernia repair as manifested by inability to do
ADL’s such as bathing, eating, toileting and grooming
without assistance and presence of abdominal binder.
Scientific Basis:
Anemia, a lower than normal hemoglobin level, is a result
of decreased hemoglobin production, increased red blood
25 | P a g e
R: L-tryptophan in milk induces sleep.
Independent Interventions:
1. Noted presence of pain, discomfort and difficulty
of breathing. Desired Outcome:
R: May restrict movement After the course of nursing interventions the
2. Observed movement when client is unaware. patient will be able to demonstrate
R: To note any incongruencies with reports of increased strength and function of
abilities. extremities and perform activities within the
3. Assessed actual and perceived limitations and level of tolerance.
degree of deficit compared to usual status.
R: Provides comparative baseline and provides
information about needed interventions
4. Assessed response to physical activity such as
vital signs.
R: To note progression of degree of intolerance.
5. Assessed ability to sit up and stand and degree of
assistance required. Actual Outcome:
R: To determine current status and needs After 2 days of nursing interventions:
6. Monitored response to medications February 1, 2012
R: To note treatment-related factors such as side Patient’s muscle strength is 4/5, noted to be
effects and interaction of medications tired, drowsy and disoriented, unable to
7. Ascertained that patient is positioned in his perform ADL’s and reports dizziness
preferred way in bed. triggered by sitting up and standing.
R: To avoid discomfort
8. Planned activities according to patient’s level of February 2, 2012
tolerance. Generalized neuromuscular weakness still
R: To avoid overexertion noted. Dizziness upon position change was
9. Observed for change in strength to do more or not reported anymore. Demonstrated
less self-care orientation and was noted to be coherent.
R: To adjust care as indicated
10. Assist with activities such as ambulation
R: To promote safety
Independent Interventions:
1. Assessed abilities and level of deficit for Desired Outcome:
performing ADL’s Within the course of nursing interventions,
R: Aids in anticipating/ planning for meeting the patient will be able to perform self-care
individual needs. activities within the level of own ability and
2. Avoided doing things for the patient that the identify resources that can provide
 cell destruction, and blood loss. Clients will have
complaints of fatigue, decreases activity intolerance,
increased breathlessness, as well as pallor and an
increased heart rate.
Source: Fundamentals of Nursing 6th Edition Potter and
Perry p. 1073
patient can do for self, but provided assistance as assistance.
necessary.
R: These patients may become fearful and Actual Outcome:
dependent, and although assistance is helpful in After 2 days of nursing interventions:
preventing frustration, it is important for the February 1, 2012
patient to do as much as possible for self to Patient was noted to do self-care activities
maintain self-esteem and promote recovery without assistance. Eating and grooming
3. Placed patient in semi-fowler’s position or to any were assisted by SO. Generalized weakness
position she desired and disorientation were still noted.
R: To promote optimum functioning
4. Provided care such as bed making and change in February 2, 2012
clothes. Patient was still unable to do ADL’s without
R. Enhances self-worth, promote optimum assistance. Disorientation not noted.
functioning and enhances rehabilitation process.
5. Assisted in promoting hygiene.
R: To provide comfort and promote hygiene
6. Provided privacy in changing clothes.
R: To provide comfort and to prevent unnecessary
embarrassment.
7. Performed passive ROM exercises.
R: Enhances maintenance of muscle or joint
functioning.
8. Assisted client when moving up in bed or turning.
R: to decrease risk for falls
9. Instructed SO to constantly assist the patient in
doing ADL’s
R: Enhances commitment to plan of care and
supports recovery and health promotion.

DRUG STUDY

Tramadol 50mg IVTT q 12h

-Analgesic
-Opioid
A:exerts its effect through the binding of parent drug and M1 metabolite to mu-opioid receptors and through the weak inhibition of norepinephrine and serotonin reuptake
I:Moderate to moderately severe pain
C:Hypercapnia, severe bronchial asthma, significant respiratory depression, in unmonitored settings or without resuscitative equipment, hypersensitivity to opioids and tramadol
Adv: Flushing, pruritus, constipation, nausea, vomiting, xerostomia, dizziness, headache,insomnia, somnolence, myocardial infraction, pancreatitis,anaphylactoid reaction, seizure, dyspnea
N: Patient should avoid activities requiring mental alertness or coordination
>Instruct patient, family members, and caregivers to report worsening depression, suicidal ideation, or unusual changes in behavior
>Patient should report signs & symptoms of serotonin syndrome
>Avoid suddent discontinuation of the drug, as this may precipitate withdrawal syndrome
>Avoid other CNS depressants while taking this drug
>Avoid alcohol while taking this drug

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Aminoleban 500ml IV infusion OD
-Food supplement
A:Normalizes amino acid, carbohydrates, fats, vitamins and minerals in the plasma
I:Treatment of Hepatic Encephalopathy in patient with chronic liver disease
C:Patients with abnormal amino acid metabolism
Adv: Rare skin eruptions, nausea, vomiting, chills, fever, headache
N:Asses patients condition before starting therapy
>Monitor patient temperature and hydration
>Be alert to adverse reactions

Hepamerz 1 sachet mixed with 1 glass H2O OD/NGT

-ornithine oxoglurate
A:L-ornithine-L-aspartate stimulates ammonia detoxification by enhancing urea synthesis in the urea cycle. Additionally, it eliminates extrahepatic ammonia from the tissues.
I:Acute and chronic liver disease eg, liver cirrhosis, fatty liver, hepatitis, associated with hyperammonemia; especially for the treatment of neurological complications (hepatic encephalopathy).
C:Severe renal dysfunction (renal insufficiency). A serum creatinine level exceeding 3 mg/100 mL can be regarded as a reference value.
Adv:Infusion: Transient GI complaints, nausea, vomiting.
N: Administration of high doses requires monitoring of serum & urinary urea levels.

Unasyn 750mg/tab 1 tab BID PO PC

-Anti-infectives
- beta lactamase inhibitors
-Aminopenicillins
A:Binds to bacteria cell wall, resulting in cell death, spectrum is broader than that of penicillin. Addition of sulbactam increases resistance to beta-lactamase, enzymes produced by bacteria that may inactivate
ampicillin.
I:Treatment of respiratory infections
C:Hypersensitivity to drug
N:  Assess patient for infection (vital signs, wound appearance, sputum, urine, stool, and WBCs) at beginning and throughout therapy.
>Obtain a history before initiating therapy to determine previous use of and reactions to penicillins or cephalosporins. Persons with a negative history of penicillin sensitivity may still have an allergic response.
>Obtain specimens for culture and sensitivity before therapy. First dose may be given before receiving results.
> Observe patients for signs and symptoms of anaphylaxis (rash, pruritus, laryngeal edema, wheezing). Discontinue the drug and notify the physician immediately if these occur. Keep epinephrine, an
antihistamine, and resuscitation equipment close by in the event of an anaphylactic reaction.
>Caution patient to notify physician if fever and diarrhea occur, especially if stool contains blood, pus, or mucus. Advise patient not to treat diarrhea without consulting health care professional. May occur up to
several weeks after discontinuation of medication.
>Instruct patient to notify physician if symptoms do not improve.

Lactulose 20cc BID PO PC

-Hyperosmotic agent
A:Produces increased osmotic pressure within colon and acidifies its contents, resulting in increased stool water content and stool softening. Causes migration of ammonia from blood into colon, where it is
converted to ammonium ion and expelled through laxative action.
I:Treatment of constipation; prevention and treatment of portal-systemic encephalopathy, including stages of hepatic precoma and coma.
C:Patients who require low-galactose diet.
Adv:Gaseous distention with flatulence or belching, abdominal discomfort and cramping; diarrhea; nausea; vomiting.
N: Advise patient that drug can be mixed with fruit juice, water, or milk to make it more palatable.
>Inform patient that drug may cause belching, flatulence, or abdominal cramps. Instruct patient to notify health care provider if these symptoms become bothersome or if diarrhea occurs.
>Instruct patient not to take other laxatives while receiving lactulose therapy.
>Encourage patient to increase dietary fiber and fluid intake and participate in regular exercise.

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Remitidine 50mg IVN q 8h
-Anti-ulcer agents
-Histamine H2 antagonists
A: Inhibits the action of histamine at the H2 receptor site located primarily in gastric parietal cells, resulting in inhibition of gastric acid secretion.
I:Treatment and prevention of heartburn, acid indigestion, and sour stomach.
C:Hypersensitivity, Cross-sensitivity may occur; some oral liquids contain alcohol and should be avoided in patients with known intolerance
Adv:Confusion, dizziness, drowsiness, hallucinations, headache,Arrhythmias, Altered taste, black tongue, constipation, dark stools, diarrhea, drug-induced hepatitis, nausea,Decreased sperm count, impotence,
Gynecomastia,Agranulocytosis, Aplastic Anemia, neutropenia, thrombocytopenia
N:Assess patient for epigastric or abdominal pain and frank or occult blood in the stool, emesis, or gastric aspirate
>Nurse should know that it may cause false-positive results for urine protein; test with sulfosalicylic acid
>Inform patient that it may cause drowsiness or dizziness.
>Inform patient that increased fluid and fiber intake may minimize constipation.
>Advise patient to report onset of black, tarry stools; fever, sore throat; diarrhea; dizziness; rash; confusion; or hallucinations to health car professional promptly
>Inform patient that medication may temporarily cause stools and tongue to appear gray black.

Albumin drip 25% OD

-Volume expander
A:Maintains blood volume. It is used in the treatment of shock, burns or low blood protein to temporarily correct or prevent a blood volume deficiency.

I:Acute respiratory distress syndrome, burns, cardiopulmonary bypass operation, hypovolemic shock
C:Hypersensitivity to albumin, patients at risk for acute circulatory overload
Adv:fever, chills, flushing, hives, skin rash, itching, headache, nausea, breathing difficulty, rapid heart rate

N:Carries a risk of transmitting infectious agents

>Instruct patients to report signs & symptoms of pulmonary edema, especially in cardiac failure patiens
>Store this medication at room temperature as directed. Do not use if this contains particles. Check the expiration date on the label and properly discard of any unused medication after that time.

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 DISCHARGE PLAN
HEALTH TEACHINGS
 Advised to do handwashing before and after contact of patient
 Encouraged to keep the patient away from crowded places
 Encouraged to maintain adequate hygiene practices
 Advised to have adequate sleep and rest
 Instructed to prioritize activities and establish balance between activity and rest to prevent fatigue
 Encouraged SO and patient to perform frequent hand washing to prevent transmission of microorganisms and prevent infection.
 Advised to limit or avoid alcohol intake
ANTICIPATORY GUIDANCE
 Instructed to report immediately to physician other unusualities or go to the nearest health center
 Instructed to report immediately if signs of infection such as redness, swelling, pain, fever and itchiness occur
SPIRITUALITY
 Encouraged to pray frequently to GOD and thank him for the daily blessings received
 Encouraged to attend masses regularly and hear God's words
 Encouraged to have a good relationship on all family members
 Encourages to put GOD first before everything else
MEDICATIONS
 Explained the importance of religiously completing the course of pharmacologic therapy
 Instructed to avoid taking medications that may be bought over-the-counter unless prescribed by attending physician.
 Instructed to report adverse reactions of the drugs such as allergies, headache, vomiting, nausea, edema and other unusualities.
 Encouraged strict compliance to medication therapy advised by the physician.
 Emphasized the avoidance of alcohol while taking the drug therapy
INCISION
 Instructed to clean the dressing at frequent intervals
 Advised not to rub the dressing vigorously
 Advised not to do activities that requires the use of the body part where the dressing is located
 Instructed to clean incision site with water
 Encouraged splinting when coughing
 Instructed not to strain during defecation
NUTRITION
 Instructed to avoid highly seasoned foods and stimulants such as coffee, tea, cola and alcohol.
 Encouraged to eat various vegetables and fruits unless contraindicated to promote a healthy diet.
 Encouraged to have an adequate intake of foods high in Vit. C such as oranges, strawberries to boost immune system and help synthesize protein
 Encourage oral fluids as tolerated
 Encouraged to eat plenty of foods with anti-oxidants such as  tomatoes, watermelon, guava, papaya, apricots, oranges, liver, sweet potatoes, carrots, milk, egg yolks and mozzarella cheese
ENVIRONMENT
 Instructed SO to keep environment at home clean, tidy, orderly, and clutter-free.
 Instructed to keep surroundings safe for the patient by keeping away all potentially dangerous objects to prevent harm or any injuries
 Instructed to limit number of visitors or people staying with client to promote rest and avoid stress.
 Instructed to avoid places with crowds and pollutants like fumes, dust, smoke near highways and large factories
 Advised SO to keep patient’s belongings nearby her bed for easy access
 Instructed patient to avoid sun exposure because Sun exposure(uv light) is a known environtmental agent that can worsen rashes of patients with lupus

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  Advised to avoid people with active infections like upper respiratory tract infections like sinusitis , pharyngitis, tonsillitis and to avoid polluted areas.

APPENDICES

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 PATHOPHYSIOLOGY
HOST AGENT ENVIRONMENT
>E.M 64, y.o Male
>alcoholic-beverage drinker for 44
years Increase blood alcohol
>consumes 5-7 250 mL bottles/ levels Production of oxidant
month (Tanduay, San Miguel, cytochrome
Tuba)

Alcohol metabolism Generation of reactive

oxygen species and free
radicals
Acetaldehyde
Aldehyde Increased oxidative stress
Dehydrogenase
Acetate Binds to non-enzymatic
and free amino groups of Oxidative cell damage
liver cell proteins
Increase NADH Decrease NAD+ Accumulation of hepatic
Alters surface charge and macrophages and other
structure of protein WBCs
Increase in fatty Decrease fatty
molecules
acid synthesis acid oxidation
Secretion of
inflammatory cytokines
Stimulation of liver cells
Adduct formation
to produce triglycerides
Inflammation of hepatic
tissues
Triglyceride
Fatty liver steatonecrosis
accumulation in the Necrosis and apoptosis of
liver hepatocytes
hepatomegaly

Production of hepatic Stellate cells proliferate

Decreased hepatic size
nodules fibrose

Formation of constrictive Narrowing of sinusoids

bands and hepatic veins

Disruption of flow in the

hepatobiliary vascular channels Portal Hypertension Sequel B
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Hepatic insufficiency
 Sequel A

Sequel A

Reduced plasma protein Release of vasoactive

Altered Steroid hormone
Impaired bilirubin Impaired waste product substances (nitric oxide)
function
metabolism and decrease hyperbilirubinemia detoxification (protein)
Altered Oncotic Pressure Splanchnic vasodilation
conjugation of bile
hyperammonemia Dysfunction of Dysfunction of sex
jaundice
aldosterone metabolism hormones Fluid escapes from Juxtaglumerular apparatus
intravascular space to sense decrease in effective
Malabsorption of dieatary
Hepatic encephalopathy extravascular space blood volume
fat and fat soluble gynecomastia
vitamins Increased water and salt
retention and excretion of Activation of the RAA
Ammonia cross BBB and potassium mechanism
Weight loss metabolized by astrocytes
to form glutamate
hypokalemia ‘Underfiliing’ of renal
circulation and worsening
Increase glutamic level Increased GABA activity of renal vasoconstriction
ascites edema

Increased Osmotic Decreased energy supply Renal Failure

pressure to brain Increased abdominal
pressure
Swelling of astrocytes
Decreased LOC
Displacement of the bowel to
the small opening of the
Cerebral Edema Coma abdominal muscles

Death Umbilical hernia

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 Sequel B

Portosystemic shunting of blood flow from the

liver to the general circulation

Redirection of blood flow from

Shunting of ammonia and other Congestion of splenic vein
hepatic portal system to lower
toxins to general circulation
venous pressures
splenomegaly
hyperammonemia Diversion to esophageal
venous routes thrombocytopenia leukopenia anemia

Hepatic encephalopathy
Formation of esophageal
varices

Rupture of varices and

bleeding

Hypovolemic shock

death

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 GENOGRAM
Maternal Side Paternal Side Legend:

- male

- female

- Unrecalled cause of death

- Hypertension

- arthritis

- Death due to heart

attack

- Patient

ECOMAP
Family

-Strong

Friends Patient Relatives

- Moderate

- Fair

Siblings
Neighbors
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