A 55 years old male patient, Mr.

Ashok was admitted to the hospital complaining of

headache and indigestion for 15-20 days. The patient on examination showed yellowish
discoloration of sclera and tongue. There was no significant medical history. As per the
patient, he is alcoholic and use to consume 4-5 quarter of alcohol/day (in patient’s language).
An advanced CT abdomen was performed and CT scan report was suggestive of cirrhosis of
liver with portal hypertension, distended Gall Bladder with sludge, mild splenomegaly, and
mild to moderate ascites.
The lab values for LFT were above the normal range (Bilirubin: 17.0 mg/dl, Bilirubin direct:
13.0, SGPT 65.0 IU/L, SGOT: 190, Alkaline Phosphatase: 1126).
UGI endoscopy report showed grade II-III oesophageal varices. ADA test was performed
whose report was found to be within normal limit. Exfoliative cytology test for malignancy
was negative.
After completing required diagnostic procedure and clinical examinations, the physician
diagnosed as Cirrhosis of liver and started treatment with following drugs; T. Pantoprazole 40
mg OD, T. Usoliv 300 mg BD, T. Tone 100 mg OD, T. Furosemide 40 mg OD, Syp
Lactulose 10 ml HS, Inj. Vit K 10 mg IV
Identify the diagnosisList down 5 nursing diagnosis
Write down 3 nursing care plan for the management of Mr. Ashok
Mr. Ashok, a 60-year-old male with decompensated alcoholic liver cirrhosis and refractory
ascites, admitted to hospital.

 K/c/o alcoholism for 20 years and quit just few years back
 H/O liver cirrhosis diagnosed in 2019 and ascites began approximately 1 year ago.
 Non-significant family history.
 Poor dietary habits

Chief complaints

 shortness of breath (SOB), bilateral lower-leg edema, dry cough every night and
difficulty breathing when lying down and difficulty walking due to her weight and
SOB.

On Assessment

 Height: 5 ft 7 inch
 Weight: 91 kg
 Temp. :97.7degree Fahrenheit
 BP: 110/64mm/Hg
 Pulse: 68 beats/min
 Bilateral edema was present on both legs (+3)
 Notable absence of peripheral pulses – dorsalis pedis and posterior tibial
 Auscultation revealed clear respiration in posterior fields, with no wheezing, rhonchi,
or accessory muscle use upon respiration
 Abdomen showed severe ascites, a midline scar, and dull to percussion.
 Bowel sounds were present in all 4 quadrants.

Investigations:

 Chest X-ray was unremarkable

 CT abdomen was performed and CT scan report was suggestive of cirrhosis of liver
with portal hypertension, distended Gall Bladder with sludge, mild splenomegaly, and
mild to moderate ascites.
 LFT: Bilirubin: 17.0 mg/dl, Bilirubin direct: 13.0, SGPT 65.0 IU/L, SGOT: 190,
Alkaline Phosphatase: 1126

Mr. Ashok is diagnosed as alcoholic cirrhosis of the liver with ascites.

 Medication list included T. Pantoprazole 40 mg OD, T. Udiliv 300 mg BD, T. Tone

100 mg OD, Furosemide 20 mg/day, along with the Spironolactone 50 mg/day, oral
lactulose 30 ml 3 times/day as needed to achieve 2-3 soft bowel movements.
Mr. Ashok, a 60-year-old male with decompensated alcoholic liver cirrhosis and refractory
ascites, presented to hospital. His height is 5 ft 7 in, and weighed 91 kg. He is a retired bank
officer who lives alone. He was an alcoholic for 20 years and quit just a few years ago.
Cirrhosis was diagnosed in 2019, and fluid began building in her abdomen approximately 1
year ago. Family history was non-significant.

At the first visit, his review of systems was positive for abdominal pain and constipation, leg
swelling, skin rash, and insomnia. At the subsequent visit, 1 month later, he was positive for
shortness of breath(SOB), bilateral lower-leg edema, dry cough every night and difficulty
breathing when lying down and difficulty walking due to her weight and SOB.

Physical examination revealed a blood pressure of 110/64 mm/Hg, temperature of 97.7°F,

and pulse of 68. Bilateral edema was present on both legs (+3) and there was a notable
absence of peripheral pulses – dorsalis pedis and posterior tibial. Auscultation revealed clear
respiration in posterior fields, with no wheezing, rhonchi, or accessory muscle use upon
respiration.

Chest X-ray was unremarkable. Abdomen showed severe ascites, a midline scar, and new
stretch marks. Bowel sounds were present in all 4 quadrants. Her abdomen was dull to
percussion. Hepatomegaly was present, and the right-upper quadrant was tender to palpation.
Scratching on both forearms had produced an erythematous rash on her skin.

The patient reported poor dietary habits. She usually had 2 meals per day, with large gaps in
between. Lab values was significant for liver failure, prediabetes, and iron deficiency.

The lab values for LFT were above the normal range (Bilirubin: 17.0 mg/dl, Bilirubin direct:
13.0, SGPT 65.0 IU/L, SGOT: 190, Alkaline Phosphatase: 1126).
Diagnosis included alcoholic cirrhosis of the liver with ascites.

Medication list included T. Pantoprazole 40 mg OD, T. Udiliv 300 mg BD, T. Tone 100 mg
OD, Furosemide 20 mg/day, along with the Spironolactone 50 mg/day, to control her ascites.
She was also taking oral lactulose 30 ml 3 times/day as needed to achieve 2-3 soft bowel
movements.
Dietary corrections included: avoidance of huge gaps between meals; incorporation of low-
glycemic index foods into the diet; sufficient protein intake (1.2-1.5 g/kg/day) but not
overload (for controlling blood sugar).

 Write own the history collection and physical examination.

 List down 5 nursing diagnosis based on priority.
 Formulate 3 nursing care plan for the nursing management of Mr. Ashok