Clinical Paper Liver Cirrhosis

ST.
PAUL UNIVERSITY DUMAGUETE

ST. PAUL UNIVERSITY SYSTEM
COLLEGE OF NURSING
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A.Y. 2020-2021
In Partial Fulfillment of the

requirements in
Related Learning Experience
A Case Study on Liver Cirrhosis
Submitted to:
Dr. Richard Pascua, RN
Instructor
Submitted by:
March 23-24, 2021

ST. PAUL UNIVERSITY DUMAGUETE
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TABLE OF CONTENTS
CHAPTER I - CASE OVERVIEW
Introduction
Objectives
Scope
Limitation
CHAPTER II - CASE DATA AND INFORMATION
Patient’s Biographical Data
Health History
Chief Complaint
History of Present Illness
Past Health History
Family History
Functional Health Patterns
Health Perception
Nutrition and Metabolism
Elimination
Activity and Exercise
Cognitive Perceptual
Sleep and Rest
Self-perception and Self-concept
Roles and Relationship
Sexuality and Reproduction
Coping and Stress Tolerance
Values and Beliefs

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Review of Systems
Integumentary System
Head, Neck and Face
Eyes and Ear
Respiratory System
Cardiovascular System
Peripheral-vascular and Lymphatic System
Breasts
Abdomen
Genitourinary System
Motor-Musculoskeletal System
Sensory-Neurologic System
Laboratory Examination
Complete Blood Count
Serum electrolyte test
Total plasma protein test
Liver enzymes test
Arterial blood gas test
Prothrombin time
Ultrasonography
CHAPTER III - LITERATURE REVIEW
Normal Anatomy and Physiology
Theoretical Background
Name of Disease
Definition
Etiology
Clinical Manifestations
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CHAPTER IV - CASE ANALYSIS AND INTERVENTIONS
Pathophysiology
Management
Medical
Surgical
Nursing
Discharge Planning
CHAPTER V - CONCLUSIONS AND RECOMMENDATIONS
Conclusions
Recommendations
REFERENCES
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ACKNOWLEDGEMENT
The researcher would like to express his deepest gratitude and most sincere appreciation to the
following, who in one way or another have contributed in the completion and success of this clinical
paper.
First and foremost, to our Almighty God, for His unending blessings of strength, for equipping
him with enough knowledge and wisdom, and for guiding and keeping him safe during this online clinical
exposure.
He would also like to thank his parents for their unconditional support, emotionally and
financially.
To our dearest Dean of the College of Nursing, Dr. Cliford Kilat, RN, MAN, for creating the
avenue for us to enhance our skills, knowledge and attitude by exposing us and letting us experience a
clinical duty even if it was restrained into online only.
To our ever-supportive clinical instructor, Dr. Richard Pascua, RN, MAN, for supervising and
sharing his knowledge and skills to us during our online clinical duty. And also, for motivating and
guiding us to become better, more effective and responsible Paulinian student nurses.
Finally, to my client Mr. M.D.A and his significant other, for actively participating and
responding during certain procedures including physical assessment and history taking.
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ABSTRACT
This is a case of client Mr. M.D.A, 56 years old, married, a Filipino citizen and a resident of
Daro, Dumaguete City, Negros Oriental. Three weeks prior to admission, patient complained of easy
fatiguability when doing simple Activities of Daily Living, until 5 days ago, experienced dyspnea on
exertion progressed interfering with his ADL’s accompanied by skin redness/irritation. According to
significant other, the night before admission pt. was very irritable and has changes in mood. Until 3 hours
ago, pt. vomited fresh whole blood. He was admitted in Negros Oriental Provincial Hospital on March 23,
2021 with a chief complaint of, “Kutas man gud kayo sir, nya sige pa gyud ko suka, wla ko kasabot sa
ako ge pamati” as verbalized by the patient. Patient had an admitting diagnosis of Cirrhosis of the Liver.
This study encompasses the nursing history, physical assessment, and nursing procedures
performed to aid in the condition of the patient and to provide comfort. The researcher performed health
history, physical assessment and assisted during Gastric lavage – for varices; and Paracentesis – to drain
ascitic fluid as prescribed for indications such as relieving abdominal pressure from ascites and to
determine the etiology of ascites and evaluate for cancer or infection. (Aponte & O’Rourke, 2019).
Morning care and environmental care has also been given to provide comfort. Medical management
includes administration of Albumin, Furosemide, Lactulose, Metronidazole, Nexium, Spironolactone,
Vitamin K, and 1 unit of Fresh whole blood. Nursing managements were given during his admission such
as vital signs monitoring, intravenous fluid monitoring, Strict monitoring of intake and output, and
attending to her other needs such as comfort measures and health teaching.
During the course of care, researcher has recognized and prioritized three nursing problems as
follows: Ineffective breathing pattern, fluid volume excess, and activity intolerance. Researcher has
formulated nursing care plans according to these problems.
After two days of nursing care to the client, progress was noticed, as he appears calm and had an
improved level of alertness. Afebrile and vital signs were within normal range, client was able to rest and
understand the disease process and compliance to medications. Client was also able to perform activities
of daily living and participated in other activities.
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CHAPTER 1
CASE OVERRVIEW
INTRODUCTION
This is a case of client Mr. M.D.A, who sought medical support on March 23, 2021 due to
difficulty in breathing, nausea, and vomiting. He was then diagnosed with Cirrhosis of the liver. Present
admission is his 7th hospitalization. Past diagnoses were Hepatitis and hypertension (2005), Liver abscess
(2007), Pneumonia (2009), Liver cirrhosis (Jan, 2012), SOB and GI bleeding (Mar, 2012), lastly
Cholecystitis (Aug, 2012). Patient has started smoking 1 pack a day and drinking alcoholic beverage at
age 25.
Cirrhosis is a chronic, degenerative liver disease marked by diffuse destruction and fibrotic
regeneration of hepatic cells. It is classified as Laennec’s – commonly caused by alcoholism and chronic
nutritional deficiencies; Biliary cirrhosis – bile duct disorders that suppress bile flow; and Posthepatic
cirrhosis – caused by various types of Hepatitis. Typical risk factors include: Male, alcoholism, old age
(over 50), hepatitis, hypertension, obesity, hyperlipidemia, and type 2 diabetes (Sharma & Nagalli, 2020).
The first 5 risk factors have manifested on the patient.
According to the latest WHO data published in 2018 Liver Disease Deaths in Philippines reached 7,491
or 1.23% of total deaths (Global Life Partners, 2021). Aside from the fact that this case is prone to men
and in the Philippines in general due to the prevalence of Hepatitis and alcohol abuse, it will also be an
opportunity for the researcher to have a deeper understanding of the disease, its manifestations and the
disease process itself.
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OBJECTIVES
General aim of this study:
The researchers aim to formulate a comprehensive case analysis that would provide essential
knowledge in delivering quality health care for patients that has Cirrhosis of the Liver.
SPECIFIC LEARNING OBJECTIVES:
Knowledge:
 To formulate a comprehensive study on the patient's current health status
 To present interpretation of the laboratory exams
 Come up with the prioritized nursing care plan based on the subjective and objective data
manifested by the patient
 To create a specific, measurable, attainable, realistic, and time-bound plan of care designed
for patient
Skills:
 To implement thoroughly the nursing care plan.
 To gather pertinent data regarding the health background of the patient including the past
and the present health history.
 To attend the specific needs of the patient
 To conduct a thorough physical assessment of the client's condition daily to differentiate

any process
 Prepare an adequate discharge summary and plan
Attitude:
 To show genuine compassion towards the care of patient's condition
 To value the time and efforts done, as well as the learning gained from the duration of
clinical duty up to the processing of the clinical paper.
 To initiate the conversation following the several techniques used in therapeutic

communication
 Facilitate maintenance of patient's confidentiality.
 Communicate accurately and completely and document responses of the patient to

prescribed medications, treatments, and procedures to other health care professionals
clearly and in a timely manner.
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SCOPE
The researchers gathered relevant information from the patient, significant other and the patient's
chart last March 23-24, 2021 at Negros Oriental Provincial Hospital. This study discusses the medical and
nursing management given to the patient and its anatomy and physiology of the affected systems,
theoretical background and nursing care plans related to the patient's condition.
LIMITATIONS
The researchers encounter some limitations during the study and in making the clinical paper. It
includes the inadequate data as the environment of clinical duty shifted into online only, and the
fluctuating network connectivity. The researcher wasn’t able to gather information regarding the patient's
health history especially during childhood and family history because patient and significant other cannot
recall definite data.
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CHAPTER II
CASE DATA AND INFORMATION
BIOGRAPHICAL DATA
Name: M.D.A
Address: Daro, Dumaguete City, Negros Oriental
Sex: Male
Height:
Weight: 110 kg.
Age: 56 years old
Birthdate: December 25, 1972
Place of Birth: Dumaguete City, Negros Oriental
Nationality: Filipino
Marital Status: Married
Religion: Roman Catholic
Educational Attainment: High School Graduate
Occupation: Farming
Date of Admission: March 23, 2021
Source of Information:
Patient — 60%
Significant Others — 20%
Patient’s Chart — 20%
——————————-
100%
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Health History
Chief Complaint
“Kutas man gud kayo sir, nya sige pa gyud ko suka, wala ko kasabot sa akoa
pamati” – as verbalized by the patient
History of Present Illness
3 weeks PTA, patient complained of easy fatiguability when doing simple Activities of Daily
Living, until 5 days ago, experienced dyspnea on exertion progressed interfering with his ADL’s
accompanied by skin redness/irritation. According to significant other, the night before admission pt. was
very irritable and has changes in mood. Until 3 hours ago, pt. vomited fresh whole blood.
Past Health History
A. Infancy
Patient doesn’t recall the immunizations given to him during infancy. No congenital defects or
complications experienced during infancy.
B. Childhood
Patient said she never had any major childhood illnesses and has not experienced hospitalizations
during these years. Occasionally gets cough & colds but treats them with over-the-counter medications
and rest at home. No known allergies
C. Adolescent
Has not experienced hospitalization during these years. No major illnesses.
D. Adulthood
Patient started smoking 1 pack a day at age 25. In addition, he also has a daily intake of 4-5
glasses of alcoholic beverages such as Tanduay and Kulafo.
E. Medical History
Patient has no known allergies but has been hospitalized on the year 2005 due to Hepatitis and
Hypertension, on 2007 due to Liver Abscess, on 2009 due Pneumonia. By the year 2012 he has been
hospitalized due to Cirrhosis of the liver, then by March due to SOB, Gastrointestinal bleeding and in
August due to Cholecystitis. Sh-e has drug maintenance of Livolin 2 capsules Two times a day,
Propanolol 1 tab once a day, Tagamet 1 tab once a day.
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GENOGRAM
MATERNAL PATERNAL
? ? ? ?
Biliary
ESRD
Obstruction
X – DM
X – Liver CA
complication
s
LEGEND: PATIENT
MALE
FEMALE PATIENT DM – Diabetes Mellitus

ESRD – end-stage renal
X DECEASED disease
? UNKNOWN CA - Cancer
Relating to this diagram, it shows that there is a significant

relevance to the present condition of the patient where in it was
revealed that both of his parents has had and died of kidney and
liver disease. ESRD can be predisposed by a liver disease. people
with a family history of liver disease or autoimmune disease are at
an increased risk of developing these diseases themselves, and
possibly cirrhosis (U.S. National Library of Medicine, 2020)
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di.
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PHYSICAL ASSESSMENT
(March 23-24, 2021)
General appearance and Mental Status:

Received patient lying in bed, unkempt and tired. Has difficulty breathing with the use of
accessory muscles, with nausea, and increased level of irritability. With ongoing IV infusion of PNSS
1000 ml. Doctor ordered KVO.
Table No. 1 Vital Signs Measurement:
7 AM 11 AM
TEMPERATURE 37.9 37.4
PULSE RATE 100 bpm 105 bpm
RESPIRATORY RATE 30 cpm 26 cpm
BLOOD PRESSURE 100/70 90/70
O2 SATURATION 93 % 94%
*Highlighted as red are the abnormal findings.
Table No. 2 Physical Assessment
*Highlighted as red are the abnormal findings.
Assessment of System Description
Integumentary Patient has jaundice. Skin irritation (pruritus) was evident.

Petechiae present on lower extremities. Upon inspection of nails,
there was clubbing of fingers. Upon palpation of nails, capillary
refill was 4 seconds. Grade 2 pitting edema was also present.
Head, Face and Neck Head is normocephalic with no nodules observed. Symmetrically
round, hard and without lesions. Face is round with prominent,
rounded cheeks. Symmetrical facial movements. Temporal artery
elastic and nontender. Temporomandibular joint palpated in full
range motion without tenderness. Neck is midline and erect,
symmetric with centered head position and no bulging masses. Has
smooth, controlled, full range of motion of neck. Thyroid gland
non visible but palpable when swallowing. Trachea is midline.
Lymph nodes are palpable, nontender and less than 1 cm diameter.
Eyes, Ears, Nose, and Throat Eyebrows are evenly distributed and symmetrically aligned.
Eyelashes are evenly distributed and slightly curled outward. Good
alignment of eyes with coordinated eye movements. No redness,
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discharge or crusting noted on lid margins. No swelling or

drainage in lacrimal gland. Extraocular movement smooth and
symmetric with no nystagmus.
The auricles are symmetrical. Aligned to outer canthus of the eyes

and is symmetrical. No lumps, nodules or lesions. The auricles are
mobile, firm and non-tender upon palpation. The pinna recoils
when folded. Small amount of moist yellow cerumen in external
canal.
Nose is in midline, no discharges. Positive nasal flaring.
Lips are symmetrical, with no lesions. Buccal mucosa pink, moist

and without exudates. Gums pink without redness or swelling.
Tongue is positioned midline. Uvula is in midline.
Respiratory Respiratory rate is RR 30 and O2 Sat is 93%; and RR 22 and O2

95%, respectively. He has a symmetrical rise and fall of the chest
while breathing. He is complaining of difficulty in breathing with
use of accessory muscles when breathing. Absence of adventitious
sound heard. No retraction or bulging of interspaces upon
breathing. No pain or tenderness upon palpation.
Cardiovascular Positive JV distention. Pulse rate is 100 bpm and blood pressure is
100/70mmHg; and 95 bpm and blod pressure is 100/70
Peripheral and Lymphatic Pulse is regular and strong in both the upper and lower extremities.
Extremities are cool to touch. Lymph nodes are non-tender and
non-palpable. However, he has petechiae on lower extremities and
clubbing of nails with a capillary refill of 4 seconds. Also has
pitting edema with a grade of 2.
Breast and axillae Breast are symmetrical and has no presence of mass and
discharges. Both are not painful upon palpation. Areolas are darker
than the surrounding skin. No presence of venous pattern. Axillary
lymph nodes are non-tender and non-palpable.
Abdomen Abdominal Girth 70 cm. Upon liver palpation- hard and firm
Genitourinary Patient has an indwelling catheter inserted. Patient has no difficulty

and pain upon urination. However, his urinary output is only
200ml. He has no problems with bowel movement.
Motor and Musculoskeletal Normal curve of cervical, thoracic and lumbar spine. Poor gait and
has difficulty in moving and doing activities simple ADL’s.
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Sensory – Neurologic First day, patient was irritable, and has decreased level of alertness.
The following day he appears calm and has improved level of
alertness. The patient is awake, alert and oriented to time, date,
person, and event. She is responsive and answers to questions
appropriately. Identifies light touch, dull and sharp sensations.
Corneal reflex present. Pupils reactive to light and accommodation.
Able to smile, frown, wrinkle forehead, show teeth, puff cheeks.
Gag reflex present and swallows without difficulty.
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LABORATORY EXAMINATION
CLINICAL HEMATOLOGY
March 23, 2021

A complete blood count (CBC) is a blood test used to evaluate your overall health and detect a
wide range of disorders, including anemia, infection and leukemia.
A complete blood count test measures several components and features of your blood, including:
Red blood cells, which carry oxygen; White blood cells, which fight infection; Hemoglobin, the oxygen-
carrying protein in red blood cells; Hematocrit, the proportion of red blood cells to the fluid component,
or plasma, in your blood; Platelets, which help with blood clotting.
Abnormal increases or decreases in cell counts as revealed in a complete blood count may
indicate that you have an underlying medical condition that calls for further evaluation (Mayo Clinic,
2018)
Table 3
Examination Results Units Normal Values Remarks

Hematocrit 25 vol% 41-50 LOW
Hemoglobin 7 g/dl 13-18 LOW
White Blood 12 /cu.mm 5-10 ELEVATED

Cells
Platelet 135 /cu.mm 100-400 NORMAL
Patient CBC can be interpreted as anemia as evidenced by the low hematocrit and hemoglobin.
Chronic liver diseases frequently are associated with hematological abnormalities. Anemia of diverse
etiology occurs in about 75% of patients with chronic liver disease (Gonzalez-Casas et al., 2009).
Cirrhosis can significantly impair the liver function, causing a number consequences – and one of them is
anemia, a disorder of the blood in which the amounts of red blood cells are not enough (lower than
normal) to carry oxygen normally. Anemia in alcoholic liver disease is also associated with a direct toxic
effect of alcohol on the bone marrow, causing reversible suppression of hematopoiesis and subsequently
anemia with impaired platelet production and function (Stillman, 2019). Patient also has increased white
blood cells as evidenced by the presence of fever and distended abdomen brought by the ascites.
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Serum electrolyte test- is a blood test that measures levels of the body's main electrolytes:
Sodium, which helps control the amount of fluid in the body. It also helps your nerves and muscles work
properly. Chloride, which also helps control the amount of fluid in the body. It helps to measure whether
there is a deficit or imbalance of electrolytes in your body. Electrolyte test also helps in monitoring the
effectiveness of some therapies and determining the side effects of certain medications like diuretics or
angiotensin-converting enzyme inhibitors since patient is having an edema (U.S. National Library of
Medicine, 2021)
Table 4
Examination Results Normal Values Remarks

Potassium 3.7 mEq/L 3.5-5.0mEq/L Normal
Sodium 129 mEq/L 135-145 mEq/L Low

Serum Protein 4.5 g/dl 7.0-7.5 Low
Serum Albumin 2.3 g/dl 4.0-5.5 Low
Serum Globulin 4.2 g/dl 1.7-3.3 Elevated
Serum Bilirubin 2.5 mg/dl 0-0.3 Elevated
Serum electrolyte derangements are common in patients with decompensated cirrhosis (Alsaad et
al., 2018). Potassium was normal however sodium was low which depicts hyponatremia - a frequent
complication of advanced cirrhosis related to an impairment in the renal capacity to eliminate solute ‐free
water that causes a retention of water that is disproportionate to the retention of sodium, thus causing a
reduction in serum sodium concentration and hypo ‐osmolality. In patients with cirrhosis, they may have
hypervolemic (dilutional) hyponatremia because of an increase in extracellular fluid volume (Ginès &
Guevara, 2008).
In addition, low serum protein as manifested by the patient indicates a kidney of liver disorders in
which the body cannot absorb protein the way it should. Low serum albumin indicates poor liver
function. Hypoalbuminemia is the primary event in the formation of ascites in the patient. A high globulin
count is caused by chronic infections and chronic inflammation (Gounden & Ishwarlal Jialal, 2018).
Furthermore, the serum protein changes occurring in liver disease associated with parenchymal
damage are characteristically decreased in serum albumin and increased in gamma globulin levels (Teloh,
1978). The serum bilirubin concentration is a specific marker of liver disease but the sensitivity is low for
detecting liver damage and remains within normal limits in many patients with compensated liver
cirrhosis. In liver cirrhosis, portal blood flow is distorted accompanied by a decrease in hepatic clearance
of bilirubin (Ohkubo, 1994).
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Liver Enzyme Test – used to represent a series of test that can help to determine if your liver is
functioning appropriately. The standard "liver function tests" include: Alanine Transaminase (or ALT for
short): ALT is produced in the liver cells known as hepatocytes and is a very specific marker of liver cell
damage. With the help of this test, we will be able to get cirrhosis lab values of a patient. Cirrhosis
happens to be a condition that causes scarring in the liver of a patient. And the damage done is actually
known to prevent the liver from functioning as it should (Krans, 2018).
Table 5

SGPT 54 units 10-40 IU/L Elevated
SGOT 55 units 10-40 IU/L Elevated
AST and ALT are two common markers for diagnosing liver diseases. Elevated ALT and AST
levels as a result in patient’s test, indicates an organ damage from alcohol, or a diminished flow of blood
from the heart to the liver (Giannini, 2005)
Arterial blood gas (ABG) test - An ABG is a blood test that measures the acidity, or pH, and the
levels of oxygen (O2) and carbon dioxide (CO2) from an artery. The test is used to check the function of
the patient’s lungs and how well they are able to move oxygen into the blood and remove carbon dioxide
(Kaufman, 2019).
Table 6

pH 7.32 7.35-7.45 Low
PAO2 70mmHg 80-100mmhg Low

PCO2 50mmHg 35-45mmhg Elevated
HCO3 21 21-27 Normal
Patient is experiencing respiratory acidosis as evidence by the low pH and O2 and elevated CO2.
In addition, enhanced chemosensitivity to hypercapnia was found in more decompensated cirrhotic
patients and was associated with sympathetic overactivity and elevated serum progesterone, likely
representing a key mechanism underlying the "unexplained" hyperventilation observed in such patients
(Passino et al., 2012).
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A prothrombin time (PT) - test measures the amount of time it takes for your blood plasma to
clot. Prothrombin is a protein produced by your liver. Since patient has a liver cirrhosis, it is important to
test if liver is not producing the proper number of proteins and that will then result to blood not being able
to clot as it should (Mayo Clinic, 2018b).
Table 7

Prothrombin time 24 seconds 12-16 seconds Increased
When the PT is high, it takes longer for the blood to clot, just like in the case of our patient which
is 24. This usually happens because the liver is not making the right amount of blood clotting proteins, so
the clotting process takes longer. A high PT usually means that there is serious liver damage or cirrhosis
(U.S. Department of Veterans Affairs, 2019).
Ultrasonography – A test in which high-frequency sound waves (ultrasound) are bounced off
tissues and the echoes are converted into a picture. This method uses sound waves to produce images that
monitor the liver’s function. That includes the flood of blood into and out of the vital organ. This is one of
the most common diagnostic tools used to diagnose liver cirrhosis. Characteristic findings of liver
cirrhosis in ultrasound are nodular liver surface, round edge, and hypoechoic nodules in liver parenchyma
which represent regenerative nodules of cirrhotic liver.
Results: Atrophy of the right lobe. Hypertrophy of the caudate/left lobe. Increased portal vein
diameter. Marked enlargement of the spleen.
Patient has hepatomegaly and splenomegaly. During the progression of liver cirrhosis, the spleen-
derived immune cells and cytokines may travel into the injured liver via portal blood flow. Together with
the portal hypertension and congestion, this will result in splenomegaly and hypersplenism (Nugroho,
2020).
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March 24, 2021
Table 8 - CBC
Examination Results Units Normal Values Remarks

Hematocrit 35 vol% 41-50 LOW
Hemoglobin 10 g/dl 13-18 LOW
White Blood 10,500 /cu.mm 5-10 Normal

Cells
Platelet 145 /cu.mm 100-400 NORMAL
Patient still has anemia, however the numbers have elevated towards the normal range. White
blood cells have lowered as evidenced by the patient being afebrile.
Table 9 – Serum electrolytes

Potassium 3.7 mEq/L 3.5-5.0mEq/L Normal
Sodium 129 mEq/L 135-145 mEq/L Low

Serum Protein 6.5 g/dl 7.0-7.5 Low
Serum Albumin 4.0 g/dl 4.0-5.5 Normal
Serum Globulin 3.2 g/dl 1.7-3.3 Normal
Serum Bilirubin 1.5 mg/dl 0-0.3 Elevated
Albumin and Globulin have returned to normal levels. Protein has increased slightly towards
normal range. Bilirubin, although lowered, still above the normal range. Patient still has hyponatremia.
Table 10 – Liver Enzymes

SGPT 35 units 10-40 IU/L Normal
SGOT 30 units 10-40 IU/L Normal
Liver enzymes is within normal range.
Table 11 – Arterial Blood Gases

pH 7.35 7.35-7.45 Low
PAO2 90mmHg 80-100mmhg Low

PCO2 40mmHg 35-45mmhg Elevated
HCO3 21 21-27 Normal
ABG’s are within normal limits. Patient does not manifest respiratory acidosis anymore.
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CHAPTER III
LITERATURE REVIEW
ANATOMY AND PHYSIOLOGY
GASTROINTESTINAL SYSTEM
The gastrointestinal tract is essentially a tube that extends from the mouth to the anus. It has
generally the same structure throughout. There is a hollow portion of the tube known as the lumen, a
muscular layer in the middle, and a layer of epithelial cells. These layers are responsible for maintaining
the mucosal integrity of the tract (Maryniak, 2014).
Figure 1 – Gastrointestinal
System
There are three main functions of the gastrointestinal tract, including transportation, digestion,
and absorption of food. The mucosal integrity of the gastrointestinal tract and the functioning of its
accessory organs are vital in maintaining the health of your patient. Components of the gastrointestinal
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system include the mouth, esophagus, stomach, small intestine, and large intestine. The gastrointestinal
tract’s accessory organs include the liver, pancreas, and gallbladder (Jarvis, 2015 & Scanlon, 2015).
The mouth functions to break down food into smaller parts. The esophagus is the tube that allows
the passage of the food bolus from the mouth to the stomach. It plays no part in the digestive process
(Jarvis, 2015 & Scanlon, 2015).
The stomach functions to store, churn, and puree food into a substance known as chime. Gastric
juices are secreted by the cells of the stomach, contributing to chemical digestion (Jarvis, 2015 &
Scanlon, 2015).
The small intestine extends from the pylorus to the ileocecal valve. The small intestine is
composed of the duodenum, jejunum, and ileum. The primary function of the small intestine is the
absorption of vitamins and nutrients, including electrolytes, iron, carbohydrates, proteins, and fats. Most
digestion of nutrients happens here (Jarvis, 2015 & Scanlon, 2015).
The large intestine extends from the terminal ileum at the ileocecal valve to the rectum. At the
terminal ileum, the large intestine becomes the ascending colon, the transverse colon, and then the
descending colon. Following the descending colon is the sigmoid colon and the rectum. The main
function of the large intestine is water absorption. Typically, the large intestine absorbs about one and
one-half liters of water per day. It can, however, absorb up to six liters (Jarvis, 2015 & Scanlon, 2015).
The gallbladder is a pear-shaped, sac-like organ attached to the liver that serves as a storage
facility for bile. When a large or fatty meal is consumed, nerve and chemical signals (release of the
enzyme CCK) cause the gallbladder to contract. This contraction releases bile into the digestive system
(Jarvis, 2015 & Scanlon, 2015).
The liver is a very large organ located in the upper right abdomen. Blood supply to the liver arises
from both the portal vein and hepatic artery. Nearly one-quarter of our cardiac output is delivered through
the liver per minute, most of which travels through the portal vein. The blood is filtered through the liver,
which destroy debris and unwanted organisms (Jarvis, 2015 & Scanlon, 2015).
The pancreas is both an endocrine and exocrine gland. The exocrine function of the pancreas is
mainly digestive in nature and involves the secretion of pancreatic enzymes and bicarbonate (Jarvis, 2015
& Scanlon, 2015).
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THEORETICAL BACKGROUND
LIVER CIRRHOSIS
The end-stage of liver disease is called cirrhosis.
Hepatic cirrhosis is a chronic hepatic disease characterized by diffuse destruction and fibrotic
regeneration of hepatic cells. As necrotic tissue yields to fibrosis, this disease alters liver structure and
normal vasculature, impairs blood and lymph flow, and ultimately causes hepatic insufficiency. The
prognosis is better in noncirrhotic forms of hepatic fibrosis, which cause minimal hepatic dysfunction and
don’t destroy liver cells (Belleza, 2017).
Classification
These clinical types of cirrhosis reflect its diverse etiology:
 Laennec’s cirrhosis. The most common type, this occurs in 30% to 50% of cirrhotic patients, up
to 90% of whom have a history of alcoholism.
 Biliary cirrhosis. Biliary cirrhosis results in injury or prolonged obstruction.
 Postnecrotic cirrhosis. Postnecrotic cirrhosis stems from various types of hepatitis.
 Pigment cirrhosis. Pigment cirrhosis may result from disorders such as hemochromatosis.
 Cardiac cirrhosis. Cardiac cirrhosis refers to cirrhosis caused by right-sided heart failure.
 Idiopathic cirrhosis. Idiopathic cirrhosis has no known cause.
Causes
 Excessive alcohol consumption. Too much alcohol intake is the most common cause of cirrhosis
as liver damage is associated with chronic alcohol consumption.
 Injury. Injury or prolonged obstruction causes biliary cirrhosis.
 Hepatitis. The different types of hepatitis can cause postnecrotic cirrhosis.
 Other diseases. Diseases such as hemochromatosis causes pigment cirrhosis.
 Right-sided heart failure. Cardiac cirrhosis, a rare kind of cirrhosis, is caused by right-sided heart
failure
Clinical Manifestations
Clinical manifestations of the different types of cirrhosis are similar, regardless of the cause.
GI system. Early indicators usually involve gastrointestinal signs and symptoms such as
anorexia, indigestion, nausea, vomiting constipation, or diarrhea.
Respiratory system. Respiratory symptoms occur late as a result of hepatic insufficiency and
portal hypertension, such as pleural effusion and limited thoracic expansion due to abdominal
ascites, interfering with efficient gas exchange leading to hypoxia.
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Central nervous system. Signs of hepatic encephalopathy also occur as a late sign, and these are
lethargy, mental changes, slurred speech, asterixis (flapping tremor), peripheral neuritis, paranoia,
hallucinations, extreme obtundation, and ultimately, coma.
Hematologic. The patient experiences bleeding tendencies and anemia.
Endocrine. The male patient experiences testicular atrophies, while the female patient may have
menstrual irregularities, and gynecomastia and loss of chest and axillary hair.
Skin. There is severe pruritus, extreme dryness, poor tissue turgor, abnormal pigmentation, spider
angiomas, palmar erythema, and possibly jaundice.
Hepatic. Cirrhosis causes jaundice, ascites, hepatomegaly, edema of the legs, hepatic
encephalopathy, and hepatic renal syndrome.
Complications
The complications of hepatic cirrhosis include the following:
Portal hypertension. Portal hypertension is the elevation of pressure in the portal vein that
occurs when blood flow meets increased resistance.
Esophageal varices. Esophageal varices are dilated tortuous veins in submucosa of the lower
esophagus.
Hepatic encephalopathy. Hepatic encephalopathy may manifest as deteriorating mental status

and dementia or as physical signs such as abnormal involuntary and voluntary movements.
Fluid volume excess. Fluid volume excess occurs due to an increased cardiac output and
decreased peripheral vascular resistance.
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CHAPTER IV
CASE ANALYSIS AND INTERVENTIONS
PATHOPHYSIOLOGY
INFECTIONS AUTO-IMMUNE TOXIN METABOLIC DX GENETIC DX

 Hepatitis  Auto-immune  Ethanol  Non-Alcoholic  Hereditary
hepatitis Fatty Liver hemochromatosis
 Primary biliary Disease  Wilson’s Disease
cirrhosis  Alpha-1 Anti-
 Primary trypsin
Sclerosing
Cholangitis
Liver breaks down alcohol
Chemical reaction damages its cells
Hepatocyte Damage
Inflammatory response (infiltration of Leukocytes, Lymphocytes)
Excess collagen formation
Scarring, Fibrosis (Liver is highly regenerative, but here it must

regenerate within extensively scarred/fibrotic tissue, forming nodules of
poorly functioning cells
Disruption of hepatic vasculature, biliary

production/excretion, and other liver functions
CIRRHOSIS
Increased resistance to Hepatocellular Carcinoma (HCC) (85 Decreased liver function

% of HCC’s occur in background of
blood flow through fibrotic (liver insufficiency)
cirrhosis
liver
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Peripheral Na & H2O Fluid volume

retention (oliguria)
vasodilation excess
Fluid
overload Hyponatremia,
Portal Hypertension: > 10-15 mmhg Hypokalemia
k-sparring, Na
Increased blood pressure in the
restriction
hepatic circulation Low albumin Liver unable to Liver unable dec.
synthesis synthesize to remove conjugation
Inc. mmhg in of bilirubin;
clotting factors toxins from
mesenteric tributaries dec.
or anti-
of portal vein the body
coagulant secretion of
Dec. oncotic proteins conjugated
Blood backs up pressure in bilirubin
into collateral systemic into bile
capillaries
Toxins duct; dec.
venous system Inc. hydrostatic
(ammonia) drainage of
pressure in Liver unable to
synthesize build-up, conjugated
abdominal
clotting factors cross BBB bilirubin
capillaries
Fluid exudes or anti- out of ducts
from plasma coagulant
Inc. mmHg in Portosystemic in the proteins
capillaries into HEPATIC
Splenic Vein Shunts
Fluid exudes interstitial
ENCEPHALOPATHY
(Hypersplenism) from plasma in tissues

decreased level of
Bilirubin
capillaries Prolonged > 40-50:
consciousness, irritability,
Varices: clotting time personality changes,
asterixis Jaundice,
Esophageal, gastric, Prothrombin time – Icterus
Splenomegaly Edema
rectal Fluid exudation 24 seconds
(congested,
into peritoneal Swollen lower Vit. K
enlarged spleen) extremities, Grade administration HEPATIC COMA
cavity 2 pitting edema,
capillary refill 4
Esophageal seconds Cholestasis
bleeding: anemia, (light
Increased trapping melena Bleeding Ammonia colored
ASCITES build-up (GIT) stool)
of blood cells
within. Gastric bleeding: Wt gain (110 kg), inc. Ineffective Lactulose
abdl. girth (70 cm), (Duphalac)
Caput medusa, dark dyspnea and inc. RR (30 Breathing Hemorrhage
color vomitus cpm; O2 sat – 92%) pattern
Gastric Lavage/Sengstaken
Inc. lysis: RBC, Blakemore Tube Paracentesis ( 3,000 mL);
ULCERATIVE Activity
Spironolactone 40 mg
WBC, Plt. IVTT; Furosemide COLITIS intolerance
Rectal bleeding:
blood in stool
Pancytopenia Polyps/Neoplasia
BACTERIAL
Hemorrhage PERITONITIS
Splanchnic venous (Fever – 37.9; chills, abdl
pain, dec. bowel sounds, COLON CANCER
congestion cloudy ascitic fluids
Antibiotics (Metronidazole
500 mg)
Rupture
SEPSIS
Hemorrhage
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Hepatocyte Damage
AH
AM
Accumulation of hormones that regulates
CHON metabolism altered
Na-K balance
Hypoglycemia (Fatigue)
Decreased Albumin synthesis
Dec. Bile (Fat (Hypoalbuminemia) – Albumin
malabsorption) (2.3 g/dL)
Impairment of estrogen Impaired regulation and
Steatorrhea
& androgen metabolism metabolism of vitamins
dec. oncotic mmHg, Inc. ADEK
Inc. estrogen &
hydrostatic mmHg
androgen; Inc ADH &
Fatty liver (inc. size) aldosterone)
Dec. Vitamins ADEK
Inc. estrogen & androgen Vitamin A: night

(gynecomastia, loss of hair, blindness
menstrual dysfunction, spider
angiomas, palmar erythema Vitamin D: Dec Ca
absorption, bone pain
Inc. ADH & Aldosterone and fracture)
(More H2O retention & Vitamin E: Testicular
oliguria) atrophy
Vitamin K: Prolonged
Portal Hypertension: > 10-15 mmhg PT (24 SECS), petechiae
Increased blood pressure in the on lower extremities
hepatic circulation - Vitamin K
administration
Hepato- Renal Syndrome Inc. capillary permeability: widespread
3rd spacing & dec intravascular

volume; mobilization of RAA
mechanism
Triad signs: Inc. BUN (Azotemia),

Inc. creatinine & Hypotension
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Pharmacologic Management
Generic Name: ALBUMIN, HUMAN
Brand Name: Albuminar, Albutein, Buminate, Plasbumin
PHARMACOTHERAPEUTIC: Plasma protein fraction. CLINICAL: Blood derivative.
ACTION Blood volume expander. Therapeutic Effect: Provides increase in intravascular oncotic
pressure, mobilizes fluids into intravascular space.
Usual Dosage IV: ADULTS, ELDERLY: Initially, 25 g; may repeat in 15–30 min. Maximum: 250 g
within 48 hrs.
SIDE EFFECTS
Occasional: Hypotension. Rare: High dose in repeated therapy: altered vital signs, chills, fever,
increased salivation, nausea, vomiting, urticaria, tachycardia.
ADVERSE EFFECTS/ TOXIC REACTIONS
Fluid overload may occur, marked by increased B/P, distended neck veins. Pulmonary edema may occur,
evidenced by labored respirations, dyspnea, rales, wheezing, coughing. Neurologic changes that may
occur include headache, weakness, blurred vision, behavioral changes, incoordination, isolated muscle
twitching.
NURSING CONSIDERATIONS
BASELINE ASSESSMENT Obtain B/P, pulse, respirations immediately before administration.

Adequate hydration required before albumin is administered.
INTERVENTION/EVALUATION Monitor B/P for hypotension/hypertension. Monitor Hgb, Hct, urine

specific gravity. Assess frequently for evidence of fluid overload, pulmonary edema (see Adverse
Effects/Toxic Reactions). Check skin for flushing, urticaria. Monitor I&O ratio (watch for decreased
output). Assess for therapeutic response (increased B/P, decreased edema).
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Generic Name: ESOMEPRAZOLE MAGNESIUM

Brand Name: Nexium
Classification: GASTROINTESTINAL AGENT; PROTON PUMP INHIBITOR
MOA:
A weak base that is converted to the active form in the highly acidic environment of the secretory surface
of the gastric parietal cells. Inhibits the enzyme H+K+-ATPase (the acid pump). Due to inhibition of the
H+K+-ATPase, esomeprazole substantially decreases both basal and stimulated acid secretion through
inhibition of the acid pump in parietal cells.
Dosage: PO 40 mg BID at least 1 h before meals.
Adverse Effects:
CNS: Headache. GI: Nausea, vomiting, diarrhea, constipation, abdominal pain, flatulence, dry mouth.
Nursing Implications:
Assessment & Drug Effects
- Monitor for S&S of adverse CNS effects (vertigo, agitation, depression) especially in severely ill
patients.
- Monitor phenytoin levels with concurrent use.
- Monitor INR/PT with concurrent warfarin use.
- Lab tests: Periodic liver function tests, CBC, Hct & Hbg, urinalysis for hematuria and proteinuria.
Patient & Family Education
- Report any changes in urinary elimination such as pain or discomfort associated with urination to
physician.
- Report severe diarrhea. Drug may need to be discontinued.
- Do not breast feed while taking this drug without consulting physician.
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Generic Name: Furosemide
Brand Name: Lasix
PHARMACOTHERAPEUTIC: Loop diuretic. CLINICAL: Diuretic.
ACTION
Enhances excretion of sodium, chloride, potassium by direct action at ascending limb of loop of Henle.
Therapeutic Effect: Produces diuresis, lowers B/P
INDICATIONS/ROUTES/DOSAGE
Edema, Heart Failure, Hypertension
IV, IM: ADULTS, ELDERLY: 20–40 mg/dose; may increase by 20 mg/dose q1–2h. Maximum single
dose: 160–200 mg.
SIDE EFFECTS
Expected: Increased urinary frequency/volume. Frequent: Nausea, dyspepsia, abdominal cramps,

diarrhea or constipation, electrolyte disturbances. Occasional: Dizziness, light-headedness, headache,
blurred vision, paresthesia, photosensitivity, rash, fatigue, bladder spasm, restlessness, diaphoresis. Rare:
Flank pain.
ADVERSE EFFECTS/TOXIC REACTIONS
Vigorous diuresis may lead to profound water loss/electrolyte depletion, resulting in hypokalemia,
hyponatremia, dehydration. Sudden volume depletion may result in increased risk of thrombosis,
circulatory collapse, sudden death. Acute hypotensive episodes may occur, sometimes several days after
beginning therapy. Ototoxicity (deafness, vertigo, tinnitus) may occur, esp. in pts with severe renal
impairment. Can exacerbate diabetes mellitus, systemic lupus erythematosus, gout, pancreatitis. Blood
dyscrasias have been reported.
BASELINE ASSESSMENT
- Check vital signs, esp. B/P, pulse, for hypotension before administration.
- Assess baseline serum electrolytes, esp. for hypokalemia.
- Assess skin turgor, mucous membranes for hydration status; observe for edema.
- Assess muscle strength, mental status.
- Note skin temperature, moisture.
- Obtain baseline weight. Initiate I&O monitoring.
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INTERVENTION/EVALUATION
- Monitor B/P, vital signs, serum electrolytes, I&O, weight. Note extent of diuresis.
- Watch for symptoms of electrolyte imbalance: Hypokalemia may result in changes in muscle
strength, tremor, muscle cramps, altered mental status, cardiac arrhythmias; hyponatremia may
result in confusion, thirst, cold/clammy skin.
PATIENT/FAMILY TEACHING
- Expect increased frequency, volume of urination.

- Report palpitations, signs of electrolyte imbalances (noted previously), hearing abnormalities
(sense of fullness in ears, tinnitus).
- Eat foods high in potassium such as whole grains (cereals), legumes, meat, bananas, apricots,
orange juice, potatoes (white, sweet), raisins.
- Avoid sunlight, sunlamps.
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Generic Name: Lactulose
Brand Name: Duphalac
ACTION
Inhibits diffusion of NH3 into blood by converting NH3 to NH4+; enhances diffusion of NH3 from blood
to gut, where it is converted to NH4+; produces osmotic effect in colon. Therapeutic Effect: Promotes
increased peristalsis, bowel evacuation; decreases serum ammonia concentration.
Prevention of Portal-Systemic Encephalopathy
ADULTS, ELDERLY: 30–45 ml 3–4 times/day. Adjust dose q1–2 days to produce 2–3 soft stools/day
SIDE EFFECTS
Occasional: Abdominal cramping, flatulence, increased thirst, abdominal discomfort. Rare: Nausea,
vomiting.
Severe diarrhea indicates overdose. Long-term use may result in laxative dependence, chronic
constipation, loss of normal bowel function.
- Encourage adequate fluid intake.

- Assess bowel sounds for peristalsis.
- Monitor daily pattern of bowel activity, stool consistency; record time of evacuation.
- Assess for abdominal disturbances.
- Monitor serum electrolytes in pts with prolonged, frequent, excessive use of medication.
- Evacuation occurs in 24–48 hrs of initial dose.

- Institute measures to promote defecation: increase fluid intake, exercise, high-fiber diet.
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Generic Name: METRONIDAZOLE

Brand Name: Flagyl, Flagyl ER, Flagyl IV RTU, Flagyl 375, Metizol, Metric 21, Metro I.V., Noritate,
Protostat
Classification: ANTIINFECTIVE; ANTITRICHOMONAL; AMEBICIDE; ANTIBIOTIC
ACTION
Disrupts DNA, inhibiting nucleic acid synthesis. Therapeutic Effect: Produces bactericidal, antiprotozoal,
amebicidal, trichomonacidal effects. Produces anti-inflammatory, immunosuppressive effects when
applied topically.
Anaerobic Infections
PO, IV: ADULTS, ELDERLY: 500 mg q6–8h. Maximum: 4 g/day.
SIDE EFFECTS
Frequent: Systemic: Anorexia, nausea, dry mouth, metallic taste. Vaginal: Symptomatic
cervicitis/vaginitis, abdominal cramps, uterine pain. Occasional: Systemic: Diarrhea, constipation,
vomiting, dizziness, erythematous rash, urticaria, reddish-brown urine. Topical: Transient erythema, mild
dryness, burning, irritation, stinging, tearing when applied too close to eyes. Vaginal: Vaginal, perineal,
vulvar itching; vulvar swelling. Rare: Mild, transient leukopenia; thrombophlebitis with IV therapy.
ADVERSE EFFECTS/ TOXIC REACTIONS

Oral therapy may result in furry tongue, glossitis, cystitis, dysuria, pancreatitis. Peripheral neuropathy
(manifested as numbness, tingling of hands/feet) usually is reversible if treatment is stopped immediately
upon appearance of neurologic symptoms. Seizures occur occasionally.
BASELINE ASSESSMENT
- Question for history of hypersensitivity to metronidazole, other nitroimidazole derivatives (and
parabens with topical).
- Obtain specimens for diagnostic tests, cultures before giving first dose (therapy may begin before
results are known).
- Monitor daily pattern of bowel activity, stool consistency.
- Monitor I&O, assess for urinary problems.
- Be alert to neurologic symptoms (dizziness, paresthesia of extremities).
- Assess for rash, urticaria.
- Monitor for onset of superinfection (ulceration/change of oral mucosa, furry tongue, vaginal
discharge, genital/anal pruritus).
- Urine may be red-brown or dark.
- Avoid alcohol, alcohol-containing preparations (cough syrups, elixirs) for at least 48 hrs after
last dose.
- Avoid tasks that require alertness, motor skills until response to drug is established.
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- If taking metronidazole for trichomoniasis, refrain from sexual intercourse until full treatment is
completed.
- For amebiasis, frequent stool specimen checks will be necessary.
- Topical: Avoid contact with eyes.
- May apply cosmetics after application.
- Metronidazole acts on erythema, papules, pustules but has no effect on rhinophyma (hypertrophy
of nose), telangiectasia, ocular problems (conjunctivitis, keratitis, blepharitis).
- Other recommendations for rosacea include avoidance of hot/spicy foods, alcohol, extremes of
hot/cold temperatures, excessive sunlight.
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Generic Name: SPIRONOLACTONE
Brand Name: Aldactone, Novospiroton
Classification: ELECTROLYTIC AND WATER BALANCE AGENT; POTASSIUM-SPARING

DIURETIC
Mechanism of Action:
Spironolactone and its active metabolites are specific pharmacologic antagonists of aldosterone, acting
primarily through competitive binding of receptors at the aldosterone-dependent sodium-potassium
exchange site in the distal convoluted renal tubule. Spironolactone causes increased amounts of sodium
and water to be excreted, while potassium is retained. Spironolactone acts both as a diuretic and as an
antihypertensive drug by this mechanism.
Indications:
Potassium-sparing diuretic (water pill) that prevents your body from absorbing too much salt and keeps
your potassium levels from getting too low. Also treats fluid retention (edema) in people with congestive
heart failure, cirrhosis of the liver, or a kidney disorder called nephrotic syndrome.
Contraindications:
Anuria, acute renal insufficiency; progressing impairment of kidney function, hyperkalemia; pregnancy
(category D), lactation.
Dosage: 40mg via IVTT OD
Adverse Effects: CNS: Lethargy, mental confusion, fatigue (with rapid weight loss), headache,
drowsiness, ataxia. Endocrine: Gynecomastia (both sexes), inability to achieve or maintain erection,
androgenic effects (hirsutism, irregular menses, deepening of voice); parathyroid changes, decreased
glucose tolerance, SLE. GI: Abdominal cramps, nausea, vomiting, anorexia, diarrhea. Skin:
Maculopapular or erythematous rash, urticaria. Metabolic: Fluid and electrolyte imbalance (particularly
hyperkalemia and hyponatremia); elevated BUN, mild acidosis, hyperuricemia, gout. Body as a Whole:
Drug fever. Hematologic: Agranulocytosis. CV: Hypertension (post-sympathectomy patient).
Nursing Responsibilities:
Assessment & Drug Effects
- Check blood pressure before initiation of therapy and at regular intervals throughout therapy.
- Lab tests: Monitor serum electrolytes (sodium and potassium) especially during early therapy;
monitor digoxin level when used concurrently.
- Assess for signs of fluid and electrolyte imbalance, and signs of digoxin toxicity. ·
- Monitor daily I&O and check for edema. Report lack of diuretic response or development of
edema; both may indicate tolerance to drug.
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- Weigh patient under standard conditions before therapy begins and daily throughout therapy.
Weight is a useful index of need for dosage adjustment. For patients with ascites, physician may
want measurements of abdominal girth.
- Observe for and report immediately the onset of mental changes, lethargy, or stupor in patients
with liver disease.
- Adverse reactions are generally reversible with discontinuation of drug. Gynecomastia appears to
be related to dosage level and duration of therapy; it may persist in some after drug is stopped.
Patient & Family Education
- Be aware that the maximal diuretic effect may not occur until third day of therapy and that
diuresis may continue for 2–3 d after drug is withdrawn.
- Report signs of hyponatremia or hyperkalemia (see Appendix F), most likely to occur in patients
with severe cirrhosis.
- Avoid replacing fluid losses with large amounts of free water (can result in dilutional
hyponatremia).
- Weigh 2–3 times each week. Report gains/loss of 5 lb.
- Do not drive or engage in potentially hazardous activities until response to the drug is known.
- Avoid excessive intake of high-potassium foods and salt substitutes.
- Do not breast feed while taking this drug.
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Generic Name: Vitamin K
Brand Name: AquaMEPHYTON , Konakion , Mephyton
PHARMACOTHERAPEUTIC: Fat-soluble vitamin. CLINICAL: Nutritional supplement, antidote

(drug-induced hypoprothrombinemia), antihemorrhagic.
ACTION
Promotes hepatic formation of coagulation factors II, VII, IX, X. Therapeutic Effect: Essential for
normal clotting of blood.
INDICATIONS/ROUTES/DOSAGE (ALERT: PO/subcutaneous route preferred; IV/IM use restricted

to emergent situations)
PO, IV, Subcutaneous: ADULTS, ELDERLY:2.5–10 mg/dose. May repeat in 12–48 hrs if given
orally, in 6–8 hrs if given by IV or subcutaneous route.
SIDE EFFECTS (ALERT: PO/subcutaneous administration less likely to produce side effects than
IV/IM routes)
Occasional: Pain, soreness, swelling at IM injection site, pruritic erythema (with repeated injections),
facial flushing, altered taste.
Newborns (esp. premature infants) may develop hyperbilirubinemia. Severe reaction (cramp-like pain,
chest pain, dyspnea, facial flushing, dizziness, rapid/weak pulse, rash, diaphoresis, hypotension
progressing to shock, cardiac arrest) occurs rarely, immediately after IV administration.
- Monitor PT, international normalized ratio (INR) routinely in pts taking anticoagulants.
- Assess skin for ecchymoses, petechiae.
- Assess gums for gingival bleeding, erythema.
- Assess urine for hematuria. Assess Hct, platelet count, urine/stool culture for occult blood.
- Assess for decrease in B/P, increase in pulse rate, complaint of abdominal/back pain, severe
headache (may be evidence of hemorrhage).
- Assess peripheral pulses.
- Check for excessive bleeding from minor cuts, scratches.
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- Discomfort may occur with parenteral administration.

- Adults: Use electric razor, soft toothbrush to prevent bleeding.
- Report any sign of red or dark urine, black or red stool, coffee-ground vomitus, red-speckled
mucus from cough.
- Do not use any OTC medication without physician approval (may interfere with platelet
aggregation).
- Consume foods rich in vitamin K1, including leafy green vegetables, meat, cow’s milk,
vegetable oil, egg yolks, tomatoes.
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Surgical Management
Paracentesis
Severe cirrhosis can cause fluid to build up in the abdomen. Paracentesis is done to take excess fluid out.
A numbing medicine is injected. Imaging is used to help guide the needle and insert it into the belly. Fluid
will be drawn out through the needle.
NURSING MANAGEMENT
- Check for the physician’s order

- Explain to procedure to patient and patient relatives what to be going to done
- Take written consent from patient and patient relatives
- Shave and Skin prepare should be done
- Record the patient vital e.g., Temperature, BP, pulse, Spo2
- Provide privacy
- Maintain I. V, line, if any emergency to give fluids and medications
- Paint abdomen with Betadine
- Assist to Doctor, giving needed articles, such as cotton swabs, sterile towels, etc…
- Needle should be inserted z-track technique
- Monitor patient during procedure
- Observe for fluid color
- Measure fluid quantity
- Send test tube for diagnostic tests
- After finishing the procedure, seal the punctured wound with sterile dressing
- Fasten the abdominal binder tightly, from the top to bottom
After care of the patient:
- Provide any hot tea if indicated.

- Monitor patient vitals continuously.
- Monitor input and output chart.
- Watch for any reaction for 24 hours
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Gastric lavage
is the washing out of the stomach via a nasogastric tube or stomach tube. Lavage is ordered to wash out
the stomach (after ingestion of poison or an overdose of medication, for example) or to control
gastrointestinal bleeding. If the patient does not have a nasogastric tube in place already, the physician
will order the insertion of the appropriate tube.
NURSING MANAGEMENT
- Before beginning gastric lavage, explain the procedure to the patient and obtain her verbal
agreement to begin the procedure.
- Test the patient’s gag reflex; immediately report an absent gag reflex as this may indicate the
need for endotracheal intubation.
- Gather the equipment and perform hand hygiene. Ensure that a suction device and a suction
source are functional and within reach in case the patient vomits during the procedure.
- Don gloves and measure the distance of the tubing from the tip of the nose to the ear lobe to the
xiphoid process. Mark the distance on the tube with an indelible ink or with tape.
- To set up the lavage equipment, connect one of the three pieces of large-lumen tubing to the
irrigant container.
- Insert the stem of the Y connector into the other end of the tubing.
- Connect the remaining two pieces of tubing to the free ends of the Y connector.
- Place the unattached end of one of the tubes into one of the drainage containers.
- Reserve the other piece of tubing for the patient’s gastric tube.
- Clamp the tube leading to the irrigant and suspend the irrigant and the setup on the IV pole.
- Drape a towel or a disposable pad over the patient’s chest to protect her clothing and linen and
apply a topical anesthetic if prescribed. If the patient wears dentures, ask her to remove them.
- In cases of poisoning or drug overdose, typically a large bore 36 to 40 French or 30 English-
gauge orogastric tube (external diameter: 12 to 13.3 millimeters) is used for adults. Have the
patient breathe through one naris at a time; select the more patent naris for insertion.
- Place the patient in a head-down, left side-lying position to reduce the risk of aspiration if the
patient vomits. Apply a water-soluble lubricant to the first 4 inches of the distal end of the tube.
Insert the tube orally or nasally as indicated by the provider’s orders.
- Ask the patient to swallow, then advance the tube until you have inserted the appropriate length
of tubing.
- Do not use force to pass the tube, especially if the patient is struggling. Inspect the back of the
patient’s throat using a penlight and a tongue blade to ensure that the tube has not coiled.
- Temporarily secure the oro- or nasogastric tube. Ideally, proper tube placement is confirmed
radiographically. If this is not possible, aspirate gastric contents and test the pH of the aspirate.
Once you have confirmed appropriate placement, secure the tube. If gastric samples are required
for analysis, aspirate gastric contents and place the aspirate in a specimen container.
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- Carefully monitor the volume instilled and the character and volume of aspirated contents. The
volume of lavage fluid returned should approximate the amount of fluid given. Small volumes are
used to minimize the risk of gastric contents entering the duodenum during lavage, since the
amount of fluid affects the rate of gastric emptying. Warm fluids avoid the risk of hypothermia in
the very young and very old and in those receiving large volumes of lavage fluid. Continue the
lavage until the recovered lavage solution is clear of particulate matter, although a negative or
poor lavage return does not rule out a significant ingestion or gastrointestinal hemorrhage.
- Do not leave the patient alone during gastric lavage.
- Monitor vital signs, respiratory status, and the patient’s level of consciousness continuously and
report acute changes immediately to the provider.
THERAPEUTIC MANAGEMENT
• IVF Therapy
Patient was given 1L of PNSS @ KVO.
Nursing Responsibilities:
 When accessing the line and administering medication, the nurse must assess the line frequently,
watching not only for signs of infection but also for signs of infiltration.
 The nurse must use sterile technique in placing midline or central catheters because of the high
potential risk of deadly infection. Choosing the correct site for insertion of the catheter and
checking for placement after insertion.
 The nurse must also watch for signs of thrombosis or blood clots within the vein, as well as assess
the patient for adverse reactions to medications and keep the patient informed and calm during all
Bed Bath
Cleans the skin and makes the client more comfortable. It stimulates the circulation and relaxes the
patient as well. It is also a good opportunity to observe the condition of the client's body as well as
communicate with the client.
BP Monitoring
Monitored the bp of the patient since she was diagnosed hypertensive and as seen in her vital signs there
is a consistent increase of the blood pressure. The higher your blood pressure is, the higher your risk of
health problems in the future. If blood pressure is increased with no management this may lead to a heart
attack or stroke.
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Intake and Output Monitoring
Extremely accurate intake and outputs should be recorded for these patients, as it is a sensitive balancing
act to maintain adequate hydration while we are deliberately causing frequent, and often very loose stools
with medications.
Health teaching
Provided a health teaching to the patient since she has no knowledge about her disease and in order for
her to make healthy food choices, staying physically active, monitoring your intake and output, weight,
and abdominal girth and taking medications as prescribed by the doctor. To know more about the
different complications, she may acquire if it’s not prevented.
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NURSING CARE MANAGEMENT
Three priority nursing intervention.
1. Ineffective breathing pattern related to ascites and restriction of thoracic excursion secondary to
ascites, abdominal distention, and fluid in the thoracic activity.
2. Activity intolerance related to fatigue, lack of energy, and altered respiratory function secondary
to ascites
3. Fluid volume excess r/t compromised regulatory mechanism secondary to cirrhosis of the liver as
manifested by weak in appearance, abdominal distention, edema, irritability, DOB with RR of 30
cpm.
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Patient’s Name: Macario D. Adamo Age: 56 Sex: Male Room#: _____

Date and Time of Admission: March 23, 2021
Admitting Diagnosis: Cirrhosis of Liver
Physician (Initials): D.F
Diet: Sodium restriction, high calorie, on general liquids
SUBJECTIVE:
“Kutas man gud kayo sir, nya sige pa gyud ko suka, wala ko kasabot sa akoa pamati. 3 weeks ago, nakabantay ko nga
nidako akoa tiyan unya maapektuhan na akoang panglihok og pagginhawa”, as verbalized by the patient
OBJECTIVE:
General status: Poor gait, weak, and dyspneic
Weight: 110 kg
Abdominal girth: 70 inches
Muscle weakness
T: 37.9
P: 100 bpm
RR: 30 cpm
BP: 100/70 mmhg
O2 saturation: 93%
Pitting edema (GRADE 2)
Hemoglobin: 7 g/dL (Low)
NURSING DIAGNOSIS:
Activity Intolerance related to imbalance of oxygen supply and demand as evidenced by fatigue, lack of energy, and
altered respiratory function secondary to ascites.
Definition:
Insufficient physiological or psychological energy to endure or complete required or desired activities due to
immobility and imbalance between oxygen supply and demand
Reference:
T Heather Herdman, et al. NANDA International, Inc. Nursing Diagnoses: Definitions & Classification 2018-2020.
New York, Thieme, 2018.
SCIENTIFIC ANALYSIS:
Hepatocyte damage Fibrosis and Scarring Obstructs biliary vascular channels Fluid shifting vessels
Ascites (weight gain, abdl. distention, dyspnea, and inc. RR, slight immobility) Dec. O2 carrying capacity of HgB
Dec. glucose dec. nutrition Dec. energy or muscle weakness = activity intolerance
Reference:
Perri, Giulia-Anna. “Ascites in Patients with Cirrhosis.” Canadian Family Physician, vol. 59, no. 12, 1 Dec. 2013, pp.
1297–1299, www.ncbi.nlm.nih.gov/pmc/articles/PMC3860926/.
PLANNING INTERVENTIONS RATIONALE EXPECTED EVALUATION

OUTCOME
After 8 hours of clinical  Monitor v/s and  To help After 8 hours of Goal met
duty: record q 4 hrs determine clinical duty:
Patient is able to do patient’s Patient is able
ADL’s but with current to do ADL’s
minimum assistance and health status but with
participate in self-care and evaluate minimum
activities. V/S within effectiveness assistance and
normal limits. of nursing participate in
interventions self-care
rendered activities. V/S
within normal
 Monitor Intake and limits.
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output  To evaluate
the proper
functioning
of his kidney
in relation to
his present
condition.
Reflects
circulating Goal partially met
status,
developing
fluid shifts,
and in
response to
therapy
 Assessed level of
activity tolerance and  Provide
degree of fatigue, baseline for
lethargy, and malaise further
when performing assessment
routine ADLs. and criteria
 Assisted with for
activities and hygiene assessment
when fatigued. of
effectiveness
 Encouraged rest and
when fatigued or interventions.
when abdominal pain  Promotes
or discomfort occurs. exercise &
hygiene
within pts.
level of
 Assist with selection tolerance
and pacing of desired  Conserve
activities and energy and
exercise protects the
 Encouraged to take liver
diet high in
carbohydrates.
 Administered
antipyretics as
prescribed.
 Attached O2 @ 4
L/m via nasal canula  Stimulates
as per doctor’s order. pts. interest
in selected
activities
 Restrict sodium and
fluid as ordered
 Provides
additional
nutrients
 For fever
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 Administer diuretics  To
as prescribed supplement
oxygen
demands of
patient’s
body
 Sodium may
be restricted
to minimize
fluid
retention in
extravascular
spaces. Fluid
restriction
may be
necessary to
prevent
dilutional
hyponatremi
a
 Use with
caution to
control
edema and
ascites, block
effect of
aldosterone
and increase
water
excretion
while sparing
potassium
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SUBJECTIVE:
OBJECTIVE:
Muscle weakness
RR: 30 cpm
BP: 100/70 mmhg
O2 saturation: 93%
Capillary refill- 4 seconds
Use of accessory muscles in breathing
Altered chest excursion
pH - 7.32
PAO2 - 70mmHg
PCO2 - 50mmHg
NURSING DIAGNOSIS:
Ineffective breathing pattern related to ascites and restriction of thoracic excursion secondary to ascites, abdominal
distention, and fluid in the thoracic activity.
Definition:
Inspiration and/or expiration that does not provide adequate ventilation
Reference:
Reference:

OUTCOME
After 8 hours of  Use pulse oximetry  Pulse oximetry After 8 hours of Goal met
clinical duty: to monitor O2 is a useful tool clinical duty:
Patient will be able to saturation and pulse to detect Patient will be
verbalize understanding rate. changes in able to
and demonstrate proper oxygenation verbalize
deep breathing early on; understanding
technique to facilitate however, for and
proper oxygenation to CO2 levels, demonstrate
alleviate end tidal CO2 proper deep
hyperventilation as monitoring or breathing
well as be free of arterial blood technique to
hypoxia and establish gases (ABGs) facilitate proper
normal breathing would need to oxygenation to
pattern be obtained. alleviate
hyperventilatio
n as well as be
 Monitor ABGs as  Increasing free of hypoxia
appropriate; note PaCO2 and and establish
changes. decreasing normal
PaO2 are signs breathing
of respiratory pattern
failure. As the
patient begins
to fail, the
respiratory rate
decreases and
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PaCO2 begins
to rise.
 Restlessness is
 Monitor for changes an early sign of
in orientation, hypoxia.
increased
restlessness, anxiety,
and air hunger.  If not
 Position patient with contraindicated
proper body , a sitting
alignment for position allows
optimal breathing for good lung
pattern. excursion and
chest
expansion.
 So that the
 Ensure that O2 appropriate
delivery system is amount of
applied to the patient oxygen is
continuously
delivered and
the patient does
not desaturate.
 To promote
 Encourage sustained deep
deep breaths inspiration
 Appropriate
 Teach patient when breathing
to inhale and exhale techniques
while doing during exercise
activities of daily are important in
living. maintaining
adequate gas
exchange.
 To supplement
 Attached O2 @ 4 oxygen
L/m via nasal canula demands of
as per doctor’s order. patient’s body
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SUBJECTIVE:
OBJECTIVE:
RR: 30 cpm
O2 saturation: 93%
Capillary refill- 4 seconds
Pitting edema Grade 2
Use of accessory muscles in breathing
Altered chest excursion
Positive JVP
Oliguria
NURSING DIAGNOSIS:
Fluid volume excess r/t compromised regulatory mechanism secondary to cirrhosis of the liver as manifested by weak
in appearance, abdominal distention, edema, irritability, DOB with RR of 30 cpm.
Definition:
Surplus intake and/or retention of fluid
Reference:
Portal hypertension (Increases blood pressure in the hepatic circulation) Inc. hydrostatic pressure in abdominal
capillaries Inc. vasodilators dec. effective blood volume felt by kidneys Kidneys retain mor
water& sodium, increasing blood volume Fluid volume excess
Reference:

OUTCOME
After 8 hours of clinical  Monitor input and  To monitor After 8 hours of Goal met
duty: output closely. fluid balance. clinical duty:
The patient will The patient will
maintain adequate fluid maintain
volume and electrolyte  Focus is on adequate fluid
balance as evidenced  Evaluate urine output monitoring volume and
by: vital signs within in response to the response electrolyte
normal limits, clear lung diuretic therapy. to the balance as
sounds, pulmonary diuretics, evidenced by:
congestion absent on x- rather than vital signs
ray, resolution of the actual within normal
edema. amount limits, clear
voided. lung sounds,
pulmonary
congestion
 Treatment absent on x-ray,
 Attach indwelling focuses on resolution of
urinary catheter. diuresis of edema.
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excess fluid.
 Institute/instruct
patient regarding  To help
fluid restrictions as reduce
appropriate. extracellular
volume. For
some
patients,
fluids may
need to be
restricted to
100 ml per
day.
 Restrict sodium  Sodium diets
intake as prescribed. of 2 to 3 gm.
are usually
 Administer or prescribed.
instruct patient to  Diuretic
take diuretics as therapy may
prescribed. include
several
different
types of
agents for
optimal
therapy,
depending on
the acuteness
or chronicity
of the
problem
 Elevate edematous  To increase
extremities. venous return
and, in turn,
decrease
edema
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DISCHARGE PLANNING:
M-
 Blood pressure medicine is used to treat high blood pressure in the portal vein (the vein that
goes to your liver).
 Diuretics decrease extra fluid that collects in a part of the body, such as the legs and abdomen.
Diuretics can also decrease the blood pressure. Patient will urinate more often when he takes this
medicine.
 Antibiotics help prevent or treat a bacterial infection.
 Take medicine as directed. Contact healthcare provider if the medicine is not helping or if you
have side effects. Tell physician if allergic to any medicine. Keep a list of the medicines,
vitamins, and herb taken. Include the amounts, and when and why you took them. Bring the list
or the pill bottles to follow-up visits. Carry medicine list in case of an emergency.
E-
 Aerobic exercises like walking, bicycling, jogging and swimming will improve your
cardiovascular system’s ability to oxygenate your blood and deliver it to the liver and the rest of
the body.
 Strength training helps maintain bone mass, increases muscle strength and mass, and helps
prevent weight gain through elevation of the metabolism.
T-
 Treat alcohol dependency in case cirrhosis is caused by alcohol abuse; Deaddiction program is
recommended.
H-
 Do not smoke. Nicotine and other chemicals in cigarettes and cigars can cause blood vessel and
lung damage. Ask your healthcare provider for information if you currently smoke and need help
to quit. E-cigarettes or smokeless tobacco still contain nicotine. Talk to your healthcare provider
before you use these products.
 Eat a variety of healthy foods. Healthy foods include fruits, vegetables, whole-grain breads,
low-fat dairy products, beans, lean meat, and fish. Ask if you need to be on a special diet.
 Reach or maintain a healthy weight. You may develop fatty liver disease if you are overweight.
Ask your healthcare provider for a healthy weight for you. He can help you create a safe weight
loss plan if you are overweight.
 Limit sodium (salt). You may need to decrease the amount of sodium you eat if you have
swelling caused by fluid buildup. Sodium is found in table salt and salty foods such as canned
foods, frozen foods, and potato chips.
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 Drink liquids as directed. Ask how much liquid to drink each day and which liquids are best for
you. For most people, good liquids to drink are water, juice, and milk. Liquids can help your liver
work better.
 Ask about vaccines. You may have a hard time fighting infection because of cirrhosis. Vaccines
help protect you against viruses that can cause diseases such as the flu or hepatitis. Viral hepatitis
is caused by a virus that leads to inflammation of the liver. You may need a hepatitis A or B
vaccine. You may also need a pneumonia vaccine. Always get a flu vaccine each year as soon as
it becomes available.
 Ask about medicines. Some medicines can harm your liver. Acetaminophen is an example. Talk
to your healthcare provider about all your medicines. Do not take any over-the-counter medicine
or herbal supplements until your healthcare provider says it is okay.
O-
 Cirrhosis can lead to a condition in the brain called hepatic encephalopathy. Hepatic
encephalopathy can happen when the liver is damaged and can’t filter toxins from the blood. It
can make you forgetful, confused, sleepy, or shaky. Your healthcare provider may prescribe
lactulose (Comalose) or rifaximin (Zaxine) if you have hepatic encephalopathy.
D-
 Some of the vegetables to avoid with cirrhosis include sauerkraut, regular tomato juice, spaghetti
sauce, tomato sauce, vegetables prepared with olives, brine and pickles, frozen peas and lima
beans. These vegetables are high in sodium and should be avoided during cirrhosis.
 Red meat isn’t approved for a cirrhosis diet, nor is any kind of processed lunch meat or sausage.
 Fiber-rich foods are useful for detoxifying toxins, removing them in the body, and helping to
balance nutrients. Types of fiber-rich foods are fresh green vegetables, whole grains, nuts, and
breads. These foods improve the digestive system, cleanse the body.
S-
 Have a strong support system from family and friends and pray for fast recovery. Also participate
in support groups that have the same experiences.
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Progress Notes
NAME OF PATIENT: ADAMO, MACARIO DATE: MARCH 23, 2021

DATE AND FOCUS DATA/ACTION/RESPONSE
TIME
March 23, 2021
7:00 AM GENERAL Data:

ASSESSMENT  Received patient lying in bed, unkempt and
tired. Has difficulty breathing with the use of
accessory muscles, with nausea, and increased
level of irritability
 With ongoing IV infusion of PNSS 1000 ml.
Doctor ordered KVO.
Action:
 Established rapport; talk and approach patient
in a calm manner
 General health status assessed; Provide
stimulation to increase alertness
 Positioned pt. comfortably in fowlers position.
 Provide patient safety
 IVF monitored and regulated
Response:
 Patient felt comfortable and relaxed
 IV is patent and infusing well
7: 15 AM VITAL SIGN
TAKING
(HYPERTHERMIA, Data:
TACHYPNEA,  Febrile with the following vital signs:
MILD T: 37.9
HYPOXEMIA) P: 100 bpm
RR: 30 cpm
BP: 100/70 mmhg
O2 Sat: 93%
Action:
 v/s monitored and recorded q 4 hrs.
 O2 Therapy @ 4 L/min via nasal canula as per
doctor’s order
 Provided medication for fever (antipyretic) as
prescribed
 Cold compress and regulated fluid intake
Response:
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8:00 AM BEDSIDE CARE No further manifestations of difficulty in breathing

AND
ENVIRONMENTAL
CARE Data:
Patient is unkempt and tired. Environment on the other
hand is disorganized and unclean.
Action:
 Tepid sponge bath
 Brushing of teeth
 Washing hair and combing afterwards
 Bed linens, pillow case, and patient gown
changed with dry and clean ones.
 Swiped and mopped floor and comfort room.
9:00 AM FOCUSED Response:

ASSESSMENT Patient is clean and comfortable
Data:
 General Health Status: weak and dyspneic
 Weight: 110 kg
 Abdominal Girth: 70 inches
 gait: Poor
 Skin and Hair: Jaundice, skin irritation
(pruritus), petechiae on lower extremities,
clubbing of nails, Capillary refill of 4 seconds,
pitting edema Grade 2.
 Chest: Pruritic rashes and redness
Action:
 Assess from time-to-time patients’ level of
consciousness and observe closely for changes
in behavior and mentation
 Continued O2 therapy as ordered
 Provide safety and assistance in ambulation
 Change positions q 2 hours
 Continued strict monitoring of intake and
output, patient weight and abdominal girth.
 Insert Indwelling catheter as ordered
 Medications administered as prescribed
- Spironolactone 40mg IVTT
- Nexium 40 mg
- Metronidazole 500 mg
10:00 AM LABORATORY Response:

EXAMINATION Patient is responsive and cooperative to the
ORDERED interventions
Output: urine – 200 mL (at Urine Collection Bag)
Action:
 Labs ordered (CBC, serum electrolytes,
albumin, bilirubin, protein, ABG, urinalysis,
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11:00 AM VITAL SIGN liver enzyme, UTZ WA, BUN, and creatinine)
TAKING
(TACHYPNEA, Response:
MILD Patient was responsive and cooperative
HYPOXEMIA)
Data:
V/S:
- T- 37.4
- RR- 26
- O2 Sat- 94%
- P- 105
- BP- 90/70
Action:
Continues O2 therapy as ordered by the doctor.
1:00 PM LABORATORY Encourage deep breathing exercises.
EXAM RESULTS
Response:
Patient manifested no difficulty in breathing and
temperature has subsided.
Data:
Requested lab results received
Action:
Informed and referred to attending physician
2:00 PM CONTINUED Response:

ASSESMENT Physician received the results
Data:
Current level of IVF = 760 ml
Action:
Checked patency of catheter
Monitored and regulated IVF
4:00 PM END OF SHIFT Response:

IVF is patent and infusing well
Catheter is patent and Urobag is sealed and not full
Data:
Urine Output: 200 cc
Action:
Monitored Vital signs

Continued strict monitoring of Intake and output
ENDORSED TO Provided important reminders to patient and
NOD significant other
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Response:
Vital signs within normal limits
Name of Patient: Adamo, Macario Age: 56 y.o Date: March 24, 2021
DATE AND FOCUS DATA/ACTION/RESPONSE
TIME
March 24, 2021
7:00 AM GENERAL Data:

ASSESSMENT  Received patient lying in bed, appears calm
and improved level of alertness
 With ongoing IV infusion of PNSS 1000 ml.
Doctor ordered KVO.
Action:
 General health status assessed
 Positioned pt. comfortably in fowlers position.
 Provide patient safety
 IVF monitored and regulated
Response:
 Patient felt comfortable and relaxed
 IV is patent and infusing well
VITAL SIGN
7: 15 AM TAKING (MILD
HYPOXEMIA) Data:
Afebrile with the following vital signs:
T: 37
P: 89 bpm
RR: 23 cpm
BP: 90/70 mmhg
O2 Sat: 94%
Action:
 v/s monitored and recorded q 4 hrs.
 O2 Therapy @ 4 L/min via nasal canula as per
doctor’s order
Response:
No further manifestations of difficulty in breathing
8:00 AM BEDSIDE CARE
AND
ENVIRONMENTAL
Data:
CARE
Patient is unkempt and tired. Environment on the other
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hand is disorganized and unclean.

Action:
 Tepid sponge bath
 Brushing of teeth
 Washing hair and combing afterwards
 Swiped and mopped floor and comfort room.
Response:
Patient is clean and comfortable
9:00 AM ASSESSMENT
Data:
 General Health Status: appears calm and
improved level of awareness
 Feels incontinent and incomplete bladder
emptying
Action:
 Assess from time-to-time patients’ level of
consciousness and observe closely for changes
in behavior and mentation
 Provide safety and assistance in ambulation
 Change positions q 2 hours
 Continued strict monitoring of intake and
output, patient weight and abdominal girth.
 Continued existing meds and administer the
following (additional):
- Vita K
- Lactulose (Duphalac)
 Start Albumin Infusion + Furosemide
- - to follow FWB 1 unit
 NGT Insertion (lavage)
 Assist in paracentesis
Response:
Patient is responsive and cooperative to the
interventions
Output: urine – 200 mL (at Urine Collection Bag)
10:00 AM LABORATORY Paracentesis Output – 3000 ml
EXAMINATION
ORDERED
Action:
 For repeat labs: CBC, U/A, SE and Serum
albumin, liver enzymes and ABG
11:00 AM VITAL SIGN Response:

TAKING ( Patient was responsive and cooperative
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Data:
V/S:
- T- 37.5
- RR- 22
- O2 Sat- 95%
- P- 95
- BP- 100/70
Action:
Continues O2 therapy as ordered by the doctor.
11:30 PM LABORATORY
EXAM RESULTS Response:
Patient manifested no difficulty in breathing; vital
signs within normal limits
Data:
Requested lab results received
Action:
Informed and referred to attending physician
Response:
12:00 PM CONTINUED Physician received the results
ASSESMENT
Action:
Checked patency of catheter
Monitored and regulated IVF
Response:
IVF is patent and infusing well
Catheter is patent and Uroag is sealed and not full
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CHAPTER V
CONCLUSIONS AND RECOMMENDATIONS
CONCLUSION:
After accomplishing the study, I was able to learn more about the disease (liver cirrhosis) and its
disease process, learn more how to manage and deal with patients who has this disease, appreciate the
importance of preventive measures and health teachings about the disease, and appreciate the significance
of nursing roles in the management of the patient’s condition. I also came to realize how important it is to
be a responsible drinker and be discipline in drinking alcohol.
The researcher also concludes, that it is very important to perform a thorough physical assessment
of the client's condition in order for us to formulate a comprehensive study on the patient's current health
status, and present the interpretation of the manifestations. It will also help us formulate and implement
an effective nursing care and attend her specific needs to improve health status.
Showing genuine compassion towards our client in providing care help us established a strong
nurse-patient relationship, with this, we were able to gather pertinent data for our clinical paper and it
made the patient realize how important health is. She became cooperative in compliance of her
medication and willingness to change her lifestyle to promote optimal health. As a student nurse, we're
exercising flexibility in dealing with situations so as to have a positive result. We believe perseverance
and determination will help us to succeed. Serving the needs of the ill is the primary role of a nurse and
that shall be enhance as we go along our journey in life.
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RECCOMENDATION
The researcher has come up with the following recommendations to improve the quality of care
given to patients with Cirrhosis of the Liver.
To the student nurses who would choose to study on cirrhosis, it is recommended that you gather
as much data and information as you can to fully comprehend the case and go into deeper context and
investigation so they may answer every question and settle confusions that may occur during the study of
the case.
To the next researchers, to ask for the past medications including the duration and doses taken by
the patient prior to admission as well as a thorough physical assessment and family history
The researcher would also like to recommend a start in the awareness of the public about this
case, and its related possible complications to old age. There is a need for the public to become aware of
the said case to help them better comprehend and decrease the occurrence of the disease using preventive
measures.
To the nurses assigned in the area, would like to recommend them to provide health teaching
during admission and after discharge to the patient as well as the significant others to promote optimal
health.
Also, the researcher would like to recommend them to ensure that the patient will take the PO
medications prescribed.
To the hospital, we would like to recommend an infection control protocol in the area in
maintaining the cleanliness and in collecting the garbage on time.
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REFERENCES
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Clinical Paper Liver Cirrhosis

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Clinical Paper Liver Cirrhosis

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ST.

PAUL UNIVERSITY DUMAGUETE

In Partial Fulfillment of the

A Case Study on Liver Cirrhosis

March 23-24, 2021

CHAPTER I - CASE OVERVIEW

CHAPTER II - CASE DATA AND INFORMATION

Patient’s Biographical Data

History of Present Illness

Past Health History

Functional Health Patterns

Nutrition and Metabolism

Activity and Exercise

Sleep and Rest

Self-perception and Self-concept

Roles and Relationship

Sexuality and Reproduction

Coping and Stress Tolerance

Values and Beliefs

Head, Neck and Face

Eyes and Ear

Peripheral-vascular and Lymphatic System

Complete Blood Count

Serum electrolyte test

Total plasma protein test

Liver enzymes test

Arterial blood gas test

CHAPTER III - LITERATURE REVIEW

Normal Anatomy and Physiology

CHAPTER V - CONCLUSIONS AND RECOMMENDATIONS

General aim of this study:

SPECIFIC LEARNING OBJECTIVES:

 To formulate a comprehensive study on the patient's current health status

 To present interpretation of the laboratory exams

 To implement thoroughly the nursing care plan.

 To attend the specific needs of the patient

 To conduct a thorough physical assessment of the client's condition daily to differentiate

 Prepare an adequate discharge summary and plan

 To show genuine compassion towards the care of patient's condition

 To initiate the conversation following the several techniques used in therapeutic

 Facilitate maintenance of patient's confidentiality.

 Communicate accurately and completely and document responses of the patient to

Address: Daro, Dumaguete City, Negros Oriental

Weight: 110 kg.

Age: 56 years old

Birthdate: December 25, 1972

Place of Birth: Dumaguete City, Negros Oriental

Marital Status: Married

Religion: Roman Catholic

Educational Attainment: High School Graduate

Date of Admission: March 23, 2021

Significant Others — 20%

Patient’s Chart — 20%

History of Present Illness

Past Health History

Has not experienced hospitalization during these years. No major illnesses.

FEMALE PATIENT DM – Diabetes Mellitus

Relating to this diagram, it shows that there is a significant

General appearance and Mental Status:

Table No. 1 Vital Signs Measurement:

*Highlighted as red are the abnormal findings.

Table No. 2 Physical Assessment

*Highlighted as red are the abnormal findings.

Assessment of System Description