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In partial fulfillment of the Requirements In

NCM-101 RELATED LEARNING EXPERIENCE A CASE STUDY On LIVER CIRRHOSIS At the ECHAGUE DISTRICT HOSPITAL

SUBMITTED BY: Ephraim Ablan Mary Aileen Asajar Dianne Melvin Buscagan Rosemarie Camposano Allyssa Marie Idorita Elaine Marjorie Figarola Neilborn Lutrania Korina Sirajani Maria Claudette Usita SUBMITTED TO: Abraham Nicolas, RN, MSN
(Clinical Instructor)

INTRODUCTION
Cirrhosis is a condition in which the liver slowly deteriorates and malfunctions due to chronic injury. Scar tissue replaces healthy liver tissue, partially blocking the flow of blood through the liver. Scarring also impairs the liver’s ability to
    

control infections remove bacteria and toxins from the blood process nutrients, hormones, and drugs make proteins that regulate blood clotting produce bile to help absorb fats—including cholesterol—and fat-soluble vitamins

A healthy liver is able to regenerate most of its own cells when they become damaged. With end-stage cirrhosis, the liver can no longer effectively replace damaged cells. A healthy liver is necessary for survival. ETIOLOGY Cirrhosis is commonly caused by excessive drinking of alcohol, drug reactions, prolonged exposure to toxic chemicals, parasitic infections and repeated bouts of heart failure with liver congestion. CAUSATIVE AGENT Alcohol, drugs, toxins and infections, autoimmune hepatitis, Nonalcoholic fatty liver disease (NAFLD), chronic hepatitis C and Chronic hepatitis B and D

CLINICAL MANIFESTATION Compensated       Intermittent mild fever Vascular spiders Palmar erythema (reddened palms) Unexplained epistaxis Ankle edema Vague morning indigestion     Flatulent dyspepsia Abdominal pain Firm, enlarged liver Splenomegaly

Decompensated        Ascites Jaundice Weakness Muscle wasting Weight loss Continuous mild fever Clubbing of fingers        Purpura (due to decreased platelet count) Spontaneous bruising Epistaxis Hypotension Sparse body hair White nails Gonadal atrophy .

The most common cause of cirrhosis is chronic hepatitis B.  The human liver is the largest single organ in the body and consists of parenchymal cells. a condition that precedes 80 percent of all liver cancers. Chronic Hepatitis B is the main reason liver cancer incidence in the Philippines is high. Cirrhosis. occurs when excessive fibrosis results in the conversion of normal liver architecture into structurally abnormal nodules. detoxify. . Normal functioning of these cells depends on their proper organization. Other possible causes of cirrhosis are hepatitis C infection and alcoholism. which metabolize. the final common pathway for a variety of liver diseases.REVIEW OF RELATED LITERATURE  The most important risk factor associated with liver cancer is cirrhosis. and store nutrients. a condition that afflicts about 10-12 percent of all Filipinos. synthesize.

however.  The cumulative probability of clinical decompensation was 22% at 1 year and 54% at 3 years after cirrhosis developed. .  The cumulative survival rate was 92% at 1 year and 78% at 5 years in patients with compensated cirrhosis. Cirrhosis is irreversible and can be life threatening—it is a public health concern because of its associated mortality and morbidity. Cirrhosis is. The only available and definitive treatment is liver transplantation. preventable in most cases.

1965 Burgos. Isabela Single Farmer Roman Catholic March 5. MA 45 y/o Male Purok 2 Diaraw. Isabela August 17. Ventura . Cristina A. 2010 Body weakness Noted sign of abdominal enlargement Conscious Attending Physician: Ma. Jones.PATIENT PROFILE Patient Name: Age: Sex: Address: Civil Status: Occupation: Religion: Birth Date: Birth Place: Date of Admission: C/c: Mr.

The gallbladder is minimally distended with suggestive tiny medium level echoes within.3*5. both paracolic gutters. Both kidneys are normal in size (RK=10.6 *5. No stones or hydronepphrosis seen.6mm. The wall is normal in thickness. Pancreas and spleen are unremarkable. It is unremarkable with no aneurysms noted. The intrahepatic and extrahepatic ducts are not dilated (CBD=45mm). REMAKS:  HEPATOMEGALY WITH LIVER CIRRHOSIS  MODERATE ASCITES  MINIMALLY DISTENDED GALL BLADDER WITH CHOLESTEROLISIS STEPHEN ISIDRO MD Radiologist Ultrasound . perisplenic. LK=6.0mm.0*5. Cortical thickness measures RK=9. Moderate amount of ascites is seen in the perihepatic.1*5.LABORATORY RESULTS ABDOMINAL ULTRASOUND The liver is enlarged with a liver span of at least 17. LK=10.2cm. and pelvic cavity.0cm.0cm) and parenchymal echogenicity. Only the proximal portion of the abdominal aorta is visualized. It shows coarse echotexture and lobulated margins. The urinary bladder is minimally distended.

Reyes MD. high altitudes ↓ in anemia.HEMATOLOGY Heb PARAMETERS Male Female Male Female X10’9/L NORMAL VALUES 140-70 120-60 . hyperthyroidism leukemia.37-4.40-. Hct . RBC X10’12/L Platelet X10’9/L Neutrophils % Lymphocytes % Monocytes % Eosinophils % Band or Srab 140-440 55-65 25-40 2-8 1-3 2-5 85 15 60% to 70% (↑ in acute infections) 20% to 25% (↑ antibody reactions) Mila Amor V. Bacterial infections often cause leukocytosis by stimulating neutrophils to increase in number.0-10.4 Leukocytosis is an abnormal high WBC. obstructive pulmonary disease.5 5. congestive heart failure.51 .44 WBC 15.0 RESULTS 147 Interpretation ↑ polycythemia. FPSI Anatomic & Clinical Patho . cirrhosis.

. And reported he  The patient perceive as long as he defecated for many times and he was rushed feel alright he consider his self to the hospital. verbalized by the patient “nakakapagod talaga trabaho sa bukid. MA had eat the food he wanted as order intake of food he stated that “Sa by doctor that his diet as tolerated except the isang araw dalawang long-neck.  Mr. day he had the ultrasound. MA doesn’t told his SO (s) if  It was July 2010 he started complaining the ever he got sick.GORDON’S FUNCTIONAL PATTERNS Before Hospitalization During Hospitalization  Mr. MA is a farmer. After voiding the patient experience dizziness  Mr. MA stays at his bed and gets up from his bed when he feel urge of defecation. MA is found of drinking alcoholic drinks even without  Mr. minsan madali akong mapagod”  The patient experience difficulty of sleeping.  Mr. Health perception and health management Nutritional –metabolic Pattern Pattern of elimination Activity-Exercise Pattern Sleep-rest pattern  The patient also experiences difficulty of sleeping due to the environment. healthy. due every afternoon he drink alcoholic drinks with his colleagues. enlargement of his abdomen.  The patient looks tiredly. emperador kasama ang mga kaibigan ko nag-iinuman” as verbalized by the patient  The patient experience loose bowel movement more or less 10X defecation/day.

Self perception-self concept pattern  The patient doesn’t show any feelings of fear or anxiety.relationship pattern Sexuality-reproductive pattern Coping stress-tolerance pattern Value-belief pattern  The patient is Roman Catholic. he has no big responsibilities in the family. At their home they are oriented with their religion and according to the patient they have strong devotion.  The patient has a enlarge abdomen.  The patient verbalized that he is still single. Never injured anyone especially when he is drunk. So.  The patient cope with his problem by drinking alcoholic drinks with his friends and doing his vices like smoking for the patient it helps in his problem. the patient stated the eldest and second eldest always done the family decision. He jokes around as if nothing is wrong. but after defecating his mood change. he looks irritable and uncomfortable.  The client feels dizzy after he defecated and feels uncomfortable. .Cognitive-perceptual pattern  The patient is behaved especially when he is drunk. He is uncomfortable with his appearance and his mobility  The patient is the third child in six siblings.  The patient is covert he solve problems by himself. Role.  He sleeps or lay on the bed to rest.

According to the patient he observes the usual enlargement of his abdomen and frequent defecating so he was rushed to the hospital and admitted.  Family Health History According to the patient the usual illness in their family are asthma and hypertension.NURSING HEALTH HISTORY Patient MA verbalized that this is his first time to be hospitalized because before he never had been hospitalized. The common illness they may have are common colds.  Present Medical History Was the date of confinement of August 17. 2010 the patient MA. RR: CR: 36cpm 128bpm BT: PR: 39. discomfort and felt dizzy.6 °C 141bpm Bowel Sounds 3spm Abdomen: 33cn length 84cm width   A grade 6 change smoker Alcoholic drinker General appearance: the patient with D5W 1L at 16 hours hooked at left arm. cough and fever. The patient can tolerate sitting and lying position and infusing well but after the patient defecated he looks pale. .

some birthmarks. INTERPRETATION NORMAL ABNORMAL due to increase of body temperature ABNORMAL due to dryness of the skin ABNORMAL due to interruption in skin integrity  Palpation   Good skin turgor NORMAL NAILS    Inspection Inspection Palpation    HEAD Convex curvature. within normal range  Moisture in skin folds  No abrasions or other lesions. freckles .PHYSICAL ASSESSMENT BODY PART ASSESSED SKIN TECHNIQUE USED  Inspection    Palpation Palpation Palpation NORMAL FINDINGS  Varies from light to deep brown  Uniform. some flat and raised nevi When pinched. angle nail with 160° Highly vascular and pink Prompt return of pink or usual color(Generally less than 4 sec)    Angle nail 160° Color : Slightly pinkish NORMAL NORMAL Good blanch Capillary test NORMAL . skin springs back to previous state     ACTUAL FINDINGS Color : Light brown Skin temperature : warm Moisture: Slightly dry Presence of lesion and scars.

Absences of nodules or masses Canthus of the eye is approximately in line with the upper tip of the ear No infection or infestation Evenly distributed Thick hair and silky. Skin intact. resilient hair   Normocephalic . uniform consistency. nodules and deppresions NORMAL NORMAL  Inspection   Canthus of the eye is approximately in line with the upper tip of the ear NORMAL  SCALP  Inspection   Absence of infection or infestation Evenly distributed Thin hair and not brittle . no discharges and discoloration Not swollen/no tenderness NORMAL NORMAL  NORMAL . Skull   Inspection Palpation   Rounded. slightly dry NORMAL  HAIR   Inspection Inspection     NORMAL NORMAL  EYES  EYEBROWS AND EYELASHES  EYELIDS  LACRIMAL   Inspection  Hair evenly distributed and symmetrically aligned  Inspection  Palpation  Skin intact. no discharges and discoloration No edema or  Normal outer. symmetrical with the outer eyebrow and eyelashes even distribution of hair with lesion on the upper part of the eye. smooth skull contour No masses. smooth skull contour Smooth.

no discharge . pinna recoils after it is folded NORMAL   Inspection Inspection      Symmetric and straight Not tender. mucosa pink Not tender  Mobile. no discharge . mucosa red in the left nostril Not tender NORMAL NORMAL NORMAL  FACIAL SINUSES  Percussion  MOUTH  LIPS  Inspection  Dark brown ABNORMAL due to smoking . firm and not tender. PERRLA NORMAL EARS  Inspection  Color same as facial skin  Color same as facial skin NORMAL  AURICLES  Palpation  NOSE Mobile. firm and not tender. shiny and smooth Black in color . Reactive to Light and Accommodation    Pale ABNORMAL due to liver disorder Yellowish or jaundice  SCLERA  PUPILS  Inspection Black .APPARATUS  CONJUNCTIVA   Inspection Inspection    tenderness ABNORMAL due to lack of oxygen Shiny. pinna recoils after it is folded Symmetric and straight Not tender. smooth and pink or red Colorless . Pupil Equally Round.

smooth. central position. Uvula positioned in midline of soft palate Muscles equal in size. moves freely. moist. soft palate. BUCCAL MUCOSA  Inspection   Uniform pink/brown color . more irregular texture Uvula positioned in midline of soft palate Muscles equal in size. Pink color. head centered No scars and mass. head centered Lymph nodes not  Red color. more irregular texture. smooth. and soft NORMAL  GUMS  Inspection    Dark brown gums ABNORMAL due to smoking  TEETH   Inspection Pink gums (+) dentures at upper and lower gums ABNORMAL due to it may cause lesion  TONGUE Inspection   GAG REFLEX   PALATE AND UVULA  Inspection Inspection     NECK   Inspection Palpation   32 teeth. smooth. cenral position. smooth. Lighter pink hard palate. and soft   No sores and red color. smooth. no tenderness. no tenderness Present Light pink. moist. white. smooth with no palpable nodules Absent Red . shiny tooth enamel Pink color. no palpable lymph nodes. trachea is at the center NORMAL       ABNORMAL it may indicate problems with glossopharyngeal NORMAL NORMAL NORMAL NORMAL NORMAL . moves freely. soft palate. Red hard palate.

RUQ ABNORMAL due to unusual enlarge abdomen ABNORMAL due to decrease of motility  Percussion   Dullness at 4 quadrant of the abdomen ABNORMAL due to large dull areas PERIPHERAL VASCULAR SYSTEM  ARMS  Palpation  Symmetric pulse volumes. or a full bladder   Auscultation   Has evidence of enlargement of liver or spleen. no edema NORMAL REFEXES . absence of arterial bruits. dullness over the liver and spleen. Full pulsation  Presence of radial pulse and brachial pulse. absence of friction rub Tympany over the stomach and gas-filled bowels. .Abdomen size: 33cm length and 84 cm width Bowel sound 3spm.THORAX (Anterior)  ABDOMEN Auscultation  palpable  Vesicular and bronchovesicular Clear breath sounds NORMAL  Inspection  No evidence of enlargement of liver or spleen Audible sounds.

 TRICEPS REFLEX   PATELLAR REFLEX  MOTOR FUNCTION  FINGERS TO THUMB  Rapidly touches each finger to thumb with each hand Percussion Percussion   +2 normal response +2 normal response   +2 +2 NORMAL NORMAL  Normally touches each finger to thumb with each hand NORMAL .

via the emulsification of lipids.  It produces bile.  Weighs 1. hepatic artery (carries blood from the aorta) portal vein (carries blood containing digested nutrients).  Detoxification. an alkaline compound which aids in digestion.  Produces albumin the major osmolar component of blood serum. FUNCTIONS  Has major role in metabolism produces bile which is important to digestive process. which merge to form bile ducts. The bile produced in the liver is collected in bile canaliculi.  Reddish brown organ with four lobes with unequal in size and shape.ANATOMY  Vital organ present in vertebrates and some other animals. Biliary Terr     The term biliary tree is derived from the arboreal branches of the bile ducts. The cystic duct from the gallbladder joins with the common hepatic duct to form the common bile duct.  Serves as storage of nutrients for later use or processed in various. Intrahepatic (within the liver) bile ducts.6 kg (largest internal organ). protein synthesis.  The liver is responsible for immunological effects. acting as a 'sieve' for antigens carried to it via the portal system.  Lies below the diaphragm in the thoracic region of the abdomen.  The two blood vessels subdivide into capillaries which then lead to a lobule. .  Connected into two large vessels. a hormone that is responsible for raising the blood pressure when activated by renin an enzyme that is released when the kidney senses low blood pressure.  The various functions of the liver are carried out by the liver cells or hepatocytes. and once they exit the liver they are considered extrahepatic (outside the liver). production of biochemicals necessary indigestion.the reticuloendothelial system of the liver contains many immunologically active cells.  The liver synthesizes angiotensinogen.4-1.

lactate or glycerol).Synthesis: protein produce and secreted water o A large part of amino acid synthesis o The liver performs several roles in carbohydrate metabolism:  Gluconeogenesis (the synthesis of glucose from certain amino acids.  Glycogenolysis (the breakdown of glycogen into glucose )  Glycogenesis (the formation of glycogen from glucose) (muscle tissues can also do this) o The liver is responsible for the mainstay of protein metabolism synthesis as well as degradation . Note that humans and some other mammals cannot synthesize glucose from glycerol.

  To have baseline of the patient’s vital sign For heat loss by evaporation and conduction. For heat loss by radiation and conduction.6°C 141 bpm  Promote surface cooling by means of removing excess linens and dressing.5°C. INTERVETION The nurse will:   Monitor vital sign. Maintain bed rest      To reduce metabolic demand.5°C and the client reported being comfortable -GOAL MET- Provide to the client a TSB. For a restful environment for the patient. DIAGNOSIS Hyperthermia r/t increased metabolic rate manifested by increase in body temperature above normal range. RATIONALE EVALUATION Within 1 hour of nursing interventions the patient body temperature decreases as evidenced by a body temperature of 37. To treat underlying condition. if there is. PLANNING Within an hour of nursing interventions the client’s body temperature will decrease at 37. Objective:  RR:  CR:  BT:  PR: 36cpm 128bpm 39.NURSING CARE PLAN ASSESSMENT Subjective: “Mainit ang pakiramdam ko” as verbalized by the patient. Promote a cool and calm environment  Administer antipyretics as ordered by the doctor  .

 Administer replacement fluids and electrolytes Provide high-calorie diet Discuss importance of adequate fluid intake  To support circulating volume and tissue perfusion To meet increased metabolic demands To prevent dehydration     .

-GOAL MET- Within an hour of The nurse will: nursing interventions the  Monitor vital sign client will Reestablish effective  Assess spontaneous respiratory pattern respiratory pattern. Objective:  Increase metabolic rate  CR: 128bpm  RR: 36cpm  Shortness of breath observable when he speak DAGNOSIS Impaired spontaneous ventilation r/t compression of diaphragm manifested by shortness of breath. and assume position of comfort. as evidenced by rhythm. symmetry of decrease in chest movement. increase cardiac rate and increase respiratory rate PLANNING INTERVENTION   RATIONALE For baseline data To measure work of breathing. practice abdominal breathing. depth. use respiratory rate of accessory muscles. EVALUATION Within an hour of nursing interventions the patient establish effective respiratory pattern via individual ability as evidenced by decrease in respiratory rate and cardiac rate. and cardiac rate  Elevate head of bed if possible   To alleviate dyspnea and to the facilitate oxygenation To maximize respiratory function Coach client to make slower. via individual ability noting rate. Instruct client in use of energy-saving techniques during care activities. To monitor if there is complication may occur.ASSESSMENT Subjective: “Minsan hindi ako makahinga lalo na pag busog ako” as verbalized by the patient.    To limit oxygen consumption . deeper breaths.

Rice. BRAT diet: Banana. 7 times of defecation per day.  Provide for changes in dietary intake.ASSESSMENT Subjective: “Lagi akong nagdudumi ” as verbalized by the patient Objective:  More or less 10 times defecation per day  Bowel sound: 3 sounds/min DIAGNOSIS Altered elimination pattern r/t compression of large intestine and increase of bilirubin manifested by More or less 10 times defecation per day. Tea    For baseline data For baseline data comparison   To allow for bowel reduced workload. -GOAL MET- Within an hour of The nurse will: nursing intervention the  Monitor vital sign client will reestablish normal  Ascertain onset and pattern of bowel pattern of diarrhea. Administer medications if ordered by the Doctor. functioning as noting whether acute evidenced by or chronic.   To supplement electrolytes and fluid loss. decrease of defecation per day  Restrict solid food at least 7 times of intake as indicated. To avoid food substances that precipitate diarrhea. defecation per day.  Encourage oral intake of fluids containing electrolytes. To decrease motility and minimize fluid losses as possible. Apple. . PLANNING INTERVENTION RATIONALE EVALUATION After an hours of nursing intervention the client had established partial pattern bowel functioning as evidenced by decrease number of defecation.

EVALUATION Within an hour of nursing intervention the client will: A. As evidenced by positive outlook from his current condition. OBJECTIVE:  Self-negating verbalization  measurement of abdomen: 34cm length 84cm width DIAGNOSIS Situational low selfesteem r/t current situational challenge to self-worth manifested by selfnegating and low self-confident PLANNING INTERVENTION RATIONALE Within 1 hour of The nurse will: nursing intervention the  Indentify basic sense of client will: self steam of client. -GOAL MET-   enhances commitment to plan optimizing outcomes  To allow the client to experience different view   the patient will be . to achieve desire outcomes  Provide feedback of client self negating remarks/behaviour.ASSESSMENT SUBJECTIVE: “Ang masyadong malaki ang tiyan ko” as verbalized by the patient. and so o Demonstrate fort self confidence by setting realistic  Assist client to problem goals and solve situation. Demonstrate self confidence by setting realistic goals and actively participating in life situation. o Acknowledge image client has of self factors that lead to possibility of  Determine client’s feelings of awareness of own low selfresponsibility for esteem. dealing with situation. actively developing plan of participating action and setting goals in life to achieve desire goals situation. Acknowledge factors that lead to possibility of feelings of low selfesteem. In order the patient to be aware of the problem that brought him to low selfesteem. Encourage involvement  In order to the patient to know what particular reasons of his low self esteem. B. personal growth. using I-messages it.

 Encourage use of visualization guided imaging.in decisions about care when possible.  aware in terms of his Health care. . and relaxation to promote positive serve of self. Convey confidence in client’s ability to cope with current situation. In order to the patient not to lose hope   In order to the patient to cope up from his condition.

napansin ko lang na masyado ng lumalaki ang tiyan ko” as verbalized by the patient Objective:  Patient’s verbalization of unawareness  Inadequate self awareness about his health condition DIAGNOSIS Deficient knowledge r/t unavailability of data presented manifested by patient’s inadequate awareness about his present health condition. PLANNING INTERVENTION RATIONALE EVALUATION Within an hour of nursing interventions the patient had verbalized understanding of health condition process as evidenced by participating in learning process. -GOAL MET- Within an hour of The nurse will: nursing intervention the client will  Determine client’s verbalize most urgent need understanding of from client’s and health condition nurses view point process as evidenced by participating in  State objectives learning process clearly in learner’s terms  Determine client’s method of accessing information and include in teaching plan Begin with information the client already knows and move to what the client does not know progressing from simple to complex Provide positive reinforcement  Identifies information that can be addressed at a later time  To meet learner’s needs  To facilitate learnings   Limits sense of being overwhelmed   Encourages continuation of efforts .ASSESSMENT Subjective: “hindi ko alam na sakit napala ito.

 Identify motivating factors for the individual Let the patient be alert to signs and avoidance  To have interest in the learning process   In order for the patient to be aware .

lifestyle changes. This may include rest. if not permanently. Encourage patient MA to take his medicine/s religiously or as needed depending on the Physician’s order. Sodium restriction will continue for a considerable time.DISCHARGE CARE PLAN MEDICATION  Explain thoroughly to Patient MA the importance of immediate or continuous treatment of liver cirrhosis. TREATMENT  Advice patient MA to seek for diagnostic evaluations. adequate dietary intake and the elimination of alcohol. and Tea). Teach the client for a change of lifestyle. Apple. HYGIENE  Let the Patient MA be informed the importance for extensive personal hygiene and as possible patient MA would perform extensive personal hygiene as part of his new change lifestyle. The success of treatment on convincing the patient of the needed to adverse completely to the therapeutic plan. Advice patient for moderate drinking alcoholic drinks and moderate smoking and if possible step by step excluding any vices that would make the health problems be worst. EXERCISE  Encourage patient MA to have some form of exercise within his potential ability to minimize complications. OPD CHECK-UP  Instruct patient to follow indicated or schedules follow up check-up for faster recovery. Rice. SPIRITUAL  Encourage Patient MA to maintain a good relationship with his personal God for Spiritual Graces. . DIET  Encourage patient MA to consume a balance diet specifically: BRAT diet (Banana. if ever conditions got worse. SOCIAL  Advise Patient MA to continue his social life as long as he knows limitations especially regarding activities.

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