CASE STUDY

Introduction About Self: - My name is Himani Sangwan, M. Sc Nursing 1st year student of ILBS Nursing College. I was
posted in private ward, Phase-2 fifth floor of ILBS hospital Vasant Kunj, from 06/11/23-10/11/23 as a part of my clinical
experience.

Introduction About The Client: - Mr. Vishnu Kant , 34 years old resident of Indranagar , Lucknow, Uttar Pradesh. He was
admitted on 02 nov 2023 in private ward with the diagnosis of CLD NASH.

Reason For Selecting This Topic For Case Study: - I found my patients case interesting and therefore, I selected CLD NASH
as my topic for case study. This will enable me to learn the comprehensive care required by such patients and therefore
enable me to develop and refine my nursing care skills including the management.

Informant :- Patient and his wife .

SOCIO DEMOGRAPHIC PROFILE

Name : Mr. Vishnu Kant

Age : 34 years

Sex : Male

Education : Hindu

Occupation : Own business

Mother tongue : Hindi

Address : Lucknow (U.P)

Ward : private ward

IP No. / UHID No. : 331860/95273

Diagnosis : CLD NASH

Date of admission : 02/11/2023

Treating physician : Dr. Rakhi Maiwall

CHIEF COMPLAINTS AT THE TIME OF ADMISSION:

Chief Complaints:

Condition on admission

 Ascites since 2 weeks

 Abdominal pain since 1 month
 Fever and vomiting since 15 days
 Shortness of breath since 1 day
 Cough since 3 days
 Jaundice since 25 days
 Pedal edema since 15 days

History of present illness:

Patient was having abdominal pain from August 2023 which was progressive. Then patient took treatment from nearby
hospital in lucknow. Then in October patient again had severe abdominal pain , vomiting and fever so he got admitted in
nearby hospital in lucknow again . He got discharged but after few days developed jaundice and then he got admitted in
Shekhar hospital , lucknow . From that hospital patient was referred to ILBS.

Past health history : History of diabetes type II since 2 month .

Past surgical history : Past surgical history is not significant.

Personal history
● Diet and nutrition: non-vegetarian. Appetite is adequate.

● Elimination patterns: Normal elimination patterns.

● Sleep pattern: Adequate.

● Activity and rest pattern: Patient do not perform exercises because of ascites and low activity tolerance .

● Leisure activity: Patient goes out with his office collegues.

● Sexual and reproductive history: Normal reproductive status. The family members have no hereditary problems related
to reproduction.

● Occupation history: He has his own business and office .

● Medication history: Patient was on treatment for jaundice from Shekar hospital , lucknow.

● Allergic reaction: No H/O any drug allergy/ food allergy.

● Immunization: H/O of immunization not known .

Social history
● Birth history: Lucknow

● Residence: Lucknow

● Education: Graduate

● Marital status: Married

Family history

● Type of family: Nuclear

● Total no of members: 4

● Number of dependents: 3

● Family pedigree:
 Male

Female
Patient

S.no Name Relation Age/sex Education Occupation Health

status
1. Vishnu kant Patient 34/male Graduate Business Unhealthy
2. Jyoti Wife 30/female Graduate Housewife Healthy
3. Shubham Son 12/ male 6th class Student Healthy
th
4. Pratiksha Daughter 10/female 4 class Student Healthy
Family disease: No history of DM/HTN hypothyroidism/CAD/Cancer and any psychiatric illness in the family.

PHYSICAL EXAMINATION
Date of physical assessment performed: 07/11/2023

General appearance

● Body built: Obese

● Nourishment: Well nourished

● Level of consciousness: Conscious

● Hygiene: Maintained

● Activity: Needs support of nurse or family member . Example : walking

Vital signs

S.NO HR Rhythm RR Blood Pressure Temp SPO2

1 108 b/min SR 22 b/min 110/70 mmhg 98.8 95%
2 102 b/min SR 24 b/min 105/67 mmhg 100.2 95%
3 104 b/min SR 22 b/min 115/72 mmhg 99.0 96%

Anthropometric Measurement

● Height: 170 cm

● Weight: 137 kg

● BMI: 47.4 kg/m2

Head to Toe Examination

Skin
● Color: Skin is pale.

● Texture: Skin is oily.

● Temperature: 98.8

● Lesions: No macules, papules, vesicles present

● Clubbing: grade 1

● Edema: Oedema over feet

Head

● Color of hair: Black

● Shape of skull: Normal

● Scalp: Clear

● Pediculosis: No pediculosis

● Texture: Texture is soft

● Hair distribution: Less

Face

● Shape: Symmetrical, Pale

● Oedema: No facial/Ocular edema

● Hydration: Face is hydrated

● Any abnormality: No any other abnormality

Eye

● Vision: No Myopia/ diplopia/ hypermetropia

● Eyebrow: Both eyebrow is in symmetrical shape

● Eye lashes: There is no evidence of eye infection

● Eyelid: Normal No stye/swelling/ptosis

● Eyeball: Eye ball is round in shape and not protruding/ Not

sunken/No exophthalmos.

● Conjunctiva: no conjunctivitis

● Sclera: pale in colour

● Cornea & Iris: Symmetrical

● Pupil: Pupil is reactive

● Lens: No opaqueness/ no crust formation

Ear

● Hearing: Patient is able to hear properly.

● External ear: Clear ear

● Tympanic membrane: There is no perforation

● Discharge: No discharge from Ear

Nose and Sinus

● Nostrils: Nostrils are normal clean

● Nasal septal deviation: There is no septal deviation

● Discharge: No discharge is present from nose

● Any bleeding from nose: No bleeding is present

● Sinus: Sinus is normal

Mouth

● Lips: Symmetrical, no cyanosis. ● Odor of mouth: No odour present

● Teeth: white teeth

● Mucous membrane & gums: There is no swelling present

● Tongue: Dry

● Tonsils: No inflammation or ulceration of tonsils

Neck

● Nuchal rigidity: Not present

● Lymph node: No lymphadenopathy

● Thyroid gland: Not palpable

● Trachea: Midline

● Carotid pulse: Palpable/No distension is present

Chest:

● Scar: No scar present

● Symmetry: Symmetrical in shape

● Colour: little pale

● Lesion: No lesion

● Chest: Symmetrical in shape & no gynecomastia, Barrel chest. Axilla

● Redness: Not present

● Lumps: Absent

● Rash: Absent

● Lymph node: Not enlarged

SYSTEMATIC EXAMINATION
Neurological system

● Coordination test: Normal

● Reflexes: Normal

● Test for sensation: Normal

● GCS: 15(E4V5M6)

Respiratory system

Inspection: Symmetrical , Barrel chest: Absent , Breathing pattern: Normal , Palpation: No tenderness , Percussion: No
free fluid present

Cardiovascular system

● Inspection and palpation: Tensed and Distended

● Auscultation: S1 and S2 normal, no murmur present

● Heart rate: 108 b/m

● Pain: no chest pain

Abdomen

● Inspection : Distended and ascites

● Auscultation : Hypoactive bowel sounds

● Percussion : Dull, free fluid present

● Palpation : tenderness, rigidity present

● Abdominal Girth : 138 cm

Genitalia & Rectum

● STD’s: Absent

● Any abnormalities: Absent

● Haemorrhoids: Absent

● Pelvic masses: Absent

● Rectal polyps: Absent

Extremities

● Movements: Voluntary movements are present

● Tremors: Absent

● Oedema: Pedal edema

● Reflexes: Present

● Varicose vein: Absent

● Clubbing of the fingers: present grade 1

● Calf muscle pain: Absent

● Homan’s sign: Negative

Spine

● Spine bifida: Absent

● Scoliosis/kyphosis/lordosis: No scoliosis found

● Curvature: Normal

● Sacral region: No scoliosis found

Impression

Abdomen was tensed and free fluid was present.

INVESTIGATION

1. Laboratory investigation

2. Radiological investigation

3. Others

Laboratory investigation

S Specimen Name of The Investigation Patients Remarks

no Values Normal values
7/11/2023 8/11/2023 9/11/2023
1 Blood Hemoglobin 12.1 12.1 12.1 11 – 16 mg/dl normal
2 Blood Sr.Magnesium 2.4 2.4 2.4 1.7-2.8mg/dl normal
3 Blood Sr.Calcium 8.2 8.2 8.2 8.4-10.2mg/dl decreased
4 Blood Sr.Bilirubin(T) 23.34 20.88 19.34 0.3-1.2mg/dl Increased
5 Blood (D)Bilirubin 11.9 10.8 09.8 0.2mg/dl Increased
6 Blood (I)Bilirubin 11.44 10.08 09.54 0.2-0.8mg/dl Increased
7 Blood AST 212 224 226 5-40IU/L Increased
8 Blood ALT 135 124 117 7-35IU/L Increased
9 Blood SAP 319 391 391 32-92IU/L Increased
10 Blood PT/INR 18.2/1.54 16.3/1.40 14.3/1.20
11 Blood TLC 20.88 20.88 20.88 4-11*10~9/L Increased
12 Blood Platelets 202 202 202 Normal
13 Blood Uric Acid 3.5 2.5 2.5 2.8-6.5mg/dl Decreased
14 Blood Sr. Sodium 131.4 131.7 131.3 136-145mmol/L Decreased
15 Blood Sr. Potassium 4.26 4.12 4.10 3.5-5mmol/L Normal
16 Blood Bicarbonate 16.4 19.8 22.2 23-29mmol/L Decreased
17 Blood S.Cr. 1.34 1.40 1.53 0.6-1.31mg/dl Increased

Radiological Examination

Chest X-ray

Rotation is normal , Bilateral lung Parenchyma are clear , Both hila and mediastinum appear normal , Domes of
diaphragm are normal , Bony cage and soft tissue are unremarkable

USG Abdomen
Impression: Chronic liver disease with findings suggestive of portal hypertension

Splenomegaly with prominent splenoportal axis and gross ascites. Endoscopy

Eradicated oesophageal varices , Mild PHG

Medications:

S.No Name of Drug Pharmacological name Frequency Dose Route

1 Inj Targocid Teicoplanin 200 mg OD 400mg IV
2 Inj ELORIS Ceftriaxone/ disodium BD 1.5gm IV
edetate/salbactum 1.5 gm
3 Tab UDCA Urodioxycholic acid 300 mg BD 450gm Oral
4 Inj Lasix Frusemide 40 mg Sos 10mg IV
5 Tab Glutathione Glutone 100 mg BD 500mg Oral
6 Tab Allomax Thiamine nitrate 300mg BD 300mg Oral
7 Tab Tamiflu Oseltamivir 75 mg BD 75mg Oral
8 Tab Deriphyllin Etofylline and theophylline 300 mg OD 200mg Oral
9 Inj Mycamine Micafungin 50 mg OD 100 mg IV
10 Inj Terlipax Terlipressin 10 mg Over 24 hour @ 0.5 IV
mg
11 Laxopeg sachet Polyethylene glycol 3350 BD 1 Oral
sachet
12 Syrup Lactihep Lactilol monohydrate syrup 66.67% BD 15 ml Oral
13 Albumin 20% Human albumin 20gm/100 ml OD 100 ml IV

Drug Dose Action Indications Contraindication Side Nursing responsibilities

effects
1.5gm Binds to Complicated Allergic to Nausea , Determine history of
Inj.Elores BD bacterial cell UTI including medicines vomiting, hypersensitivity reactions to
IV wall acute cephalosporin Injection cephalosporins and
membranes, pyelonephritis. like site pain penicillins
inhibits cell Lower penicillins, or Lab tests:
wall respiratory tract monobactams redness Perform culture and
synthesis. infection and sensitivity
including carbapenems. tests before initiation of
CAP and HCAP, therapy and periodically
Bacterial during therapy. Watch for
septicaemia and report signs:
including petechiae, ecchymotic areas,
abdominal epistaxis, or any unexplained
sepsis, Surgical bleeding . Check for fever if
prophylaxis. diarrhea .occurs
Inj. Exogenously Hypovolemia, Severe anemia, Fever , Monitor Iv albumin flow
Albumin administered Cardiopulmo cardiac failure, chills, rate , monitor
20% albumin nary Bypass patient with flushing, hypersensitivity reactions,
increases the Procedures, increased or urticaria, monitor closely for
oncotic Hypoalbuminemia, normal headache, circulatory and pulmonary
pressure of acute nephrosis intravascular backpain, edema.
the volume. Safety nausea,
intravascular during vomiting .
system, pregnancy .
pulling
 fluids from
the
interstitial
space,
thereby
decreasing
edema and
increasing
the
circulating
blood
volume.

NON-ALCOHOLIC STEATOHEPATITIS
Non-alcoholic fatty liver disease (non-alcoholic fatty liver disease, NAFLD) is the accumulation of abnormal amounts of fat
within the liver. Non-alcoholic fatty liver disease can be divided into isolated fatty liver in which there is only
accumulation of fat, and non-alcoholic steatohepatitis (NASH) in which there is fat, inflammation, and damage to liver
cells. NASH progresses to scarring and ultimately to cirrhosis, with all the complications of cirrhosis, for example,
gastrointestinal bleeding, liver failure, and liver cancer. The development of non- alcoholic fatty liver disease is intimately
associated with and is probably caused by obesity and diabetes although sometimes it occurs in individuals who are
neither obese nor diabetic. Non- alcoholic fatty liver disease is considered a manifestation of the metabolic syndrome.

Epidemiology: - It is currently estimated that the global prevalence of NAFLD is as high as one billion. In the United States,
NAFLD is estimated to be the most common cause of chronic liver disease, affecting between 80 and 100 million
individuals, among whom nearly 25% progress to NASH.

Risk factors:

Book picture Patient picture

NASH is most common in patients who are Diabetes
overweight or obese. Other risk factors include: High cholesterol
● Diabetes Obesity
● High cholesterol
● High triglycerides
● Poor diet
● Metabolic syndrome, Polycystic ovary syndrome
● Sleep apnea
● Underactive thyroid (hypothyroidism)
Causes :

Book picture Patient picture

 overweight or obesity Obesity
● insulin resistance or type 2 diabetes Diabetes millitus
● abnormal levels of fats in your blood, which may include
● high levels of triglycerides
● abnormal levels of cholesterol—high
total cholesterol, high LDL cholesterol, or low HDL
cholesterol
● metabolic syndrome or one or more traits of metabolic
syndrome. Metabolic syndrome is a group of traits and
medical conditions linked to overweight and obesity.
define metabolic syndrome as the presence of any three
 of the following
 Large waist size
 High levels of triglycerides in blood
 Low levels of HDL cholesterol in blood
 High blood pressure
 Higher than normal blood glucose levels or a diagnosis
of type 2 diabetes
Signs and symptoms:

Book picture Patient picture

 Intense itching Patient had
 Ascites  Ascites
 Bruising and bleeding easily  Jaundice
 Jaundice  Pedal edema
 Spider-like blood vessels just beneath skin’s surface
 Oedema
 Behaviour changes, slurred speech, and confusion
(hepatic encephalopathy)
If someone with NAFLD/NASH develops
cirrhosis they are also at some risk of
developing a common type of liver cancer
called hepatocellular carcinoma.
Diagnosis :

Book picture Patient picture

● Blood investigations CBC
Liver Function Tests: Direct bilirubin, indirect LFT
bilirubin, Total bilirubin, Serum albumin, Serum PT/INR
globulin, Total protein. Platelet counts, PT/INR MELD – 16
● USG abdomen CHEST X – RAY
● NCCT- abdomen ABDOMAN X-RAY
● Endoscopy FIBROSCAN
Upper GI endoscopy: For the diagnosis of
esophageal varices. Sigmoidoscopy: For the diagnosis of
rectal varices
● Liver Biopsy
● Endoscopic retrograde
cholangiopancreatography (ERCP): It is an endoscopic
procedure that combines upper gastrointestinal (GI)
endoscopy and fluoroscopy to diagnose and treat
problems of the bile and pancreatic ducts. ● Model for
end-stage liver disease (MELD) score
It is calculated according to the following
formula: - MELD = 3.78×ln[serum bilirubin (mg/dL)] +
11.2×ln[INR] + 9.57×ln[serum creatinine
(mg/dL)] + 6.43
● If the patient has been dialyzed twice
within the last 7 days, then the value for
serum creatinine used should be 4.0
mg/dL. ● Any value less than one is given a value
of 1. Interpretation
In interpreting the MELD Score in hospitalized
patients, the 3 month observed mortality is
 ● 40 or more : 71.3% observed mortality.
● 30 - 39 : 52.6% observed mortality
● 20- 29 : 19.6% observed mortality
● 10 - 19 : 6.0% observed mortality
● <9 : 1.9% observed mortality

Management :

Book picture Patient picture

Depending on the cause Injection Teicoplanin 200 mg
● Viral Hepatitis such as hepatitis B and C Injection Ceftriaxone/ disodium edetate/salbactum 1.5
Hepatitis B gm
Pegylated interferon, lamivudine, adefovir Urodioxycholic acid 300 mg tablet
dipivoxil, entecavir, telbivudine, tenofovir. Frusemide 40 mg injection
Hepatitis C NS3/4A protease inhibitors, including Glutone 100 mg tablet
telaprevir, boceprevir, simeprevir, and others NS5A Thiamine nitrate 300mg injection
inhibitors, including ledipasvir, daclatasvir, and others Oseltamivir 75 mg tablet
NS5B polymerase inhibitors, including sofosbuvir, Etofylline and theophylline 300 mg tablet
dasabuvir, and others. These drugs are used in various Micafungin 50 mg tablet
combinations, sometimes combined with ribavirin based Terlipressin 10 mg injection
on the patient's genotype. Polyethylene glycol 3350
● Hemochromatosis: Phlebotomy, chelation therapy using Human albumin 20gm/100 ml
drugs such as deferoxamine, deferasirox
● Wilson disease
Penicillamine is a chelating agent that binds
copper and leads to excretion of copper in
the urine. Zinc (usually in the form of a zinc acetate
prescription called Galzin) may be used. Zinc stimulates
metallothionein, a protein in gut cells that binds copper
and prevents their absorption and transport to the liver.
Liver transplantation is an effective cure for
Wilson disease.
● Primary sclerosing cholangitis
Moderate doses (13-15 milligrams per kilogram) of
ursodeoxycholic acid (UDCA) is recommended by the
European Association for the Study of the Liver.
Supportive therapy include antipruritics
e.g. bile acid sequestrants such as cholestyramine);
antibiotics to treat episodes of ascending cholangitis; and
vitamin supplements such as Vitamin A,D, E, K as people
with PSC are often deficient in fat-soluble vitamins.Liver
transplantation is the only proven long-term treatment of
PSC.
Indications for transplantation include recurrent bacterial
ascending cholangitis, decompensated cirrhosis,
hepatocellular carcinoma, hilar cholangiocarcinoma, and
complications of portal hypertension.
● Primary Biliary cholangitis
It is indicated for the treatment of PBC in combination
with ursodeoxycholic acid (UDCA) in adults with an
inadequate response to UDCA, or as monotherapy in
adults unable to tolerate UDCA. cholestyramine (a bile
acid sequestrant) may be prescribed to absorb bile acids in
 the gut and be eliminated, rather than re- enter the
bloodstream. Vitamin supplementation such as A,D,E,K. In
advance cases, liver transplantation is an
option. Supportive therapy
● Blood products especially packed red blood cells (PRBC),
fresh frozen plasma (FFP) in view of low platelet
count and anemia.
● Vitamin K
Vitamin K is required for the synthesis of functionally
active forms of a number of coagulation factors and
inhibitors by the liver, including prothrombin, factor VII,
XI, X, protein C, and protein S. Thus, coagulation
abnormality is a predictable feature of acute as well as
chronic liver disease. Thus, vitamin K is prescribed for
the patients with chronic liver disease.
● Acetylcysteine N-acetylcysteine (NAC) is a
hepatoprotective agent that turns into the
Amino acid L-cysteine when ingested. In turn, L-cysteine
helps produce glutathione (GSH) that helps produce the
antioxidant glutathione, which plays a key role in
protecting the liver from damage.
● Administration of albumin in view of hypoalbuminemia
and ascites.
● Abdominal paracentesis
Therapeutic paracentesis refers to the removal of five
liters or more of fluid to reduce intra-abdominal pressure
and relieve the associated dyspnea, abdominal pain, and
early satiety
● Fecal Microbiota (FMT)
Fecal Microbiota transplantation (FMT) is the
administration of a solution of fecal matter from a donor
into the intestinal tract of a recipient in order to directly
change the recipient’s gut microbial composition either
by colonoscopy, enema, orogastric tube or by mouth in
the form of a capsule containing freeze-dried material.
Surgical management :

Book picture Patient picture

● Liver transplant is the universal definite treatment for No surgical management
end stage liver disease (ESLD) or cirrhosis as a result
of chronic liver disease which replaces a failing or
damaged liver with a healthy and well-functioning one.

Complications :

Book picture Patient picture

● Portal hypertension: Portal
hypertension is high blood pressure in the hepatic portal
system. A normal HVPG is between 1 and 5 mmHg. Portal
hypertension is present if the HVPG is ≥6 mmHg. Portal
hypertension typically becomes clinically significant when
the HVPG is ≥10 mmHg, at which point varices may
develop. Once the HVPG is ≥12 mmHg, patients are at risk
 for variceal bleeding and the development of
ascites.
● Ascites : Accumulation of fluid in the
peritoneal cavity results in ascites
● Hypersplenism (with or without
splenomegaly)
Liver and spleen are closely associated via the
portal vein system. Portal hypertension in chronic liver
disease can lead to congestion of the portal system and
therefore hypersplenism and splenomegaly occurs.
● Lower oesophageal varices: extremely dilated
submucosal veins in the lower
third of the esophagus and have a strong tendency to
develop bleeding.
● Rectal varices : Dilation of collateral submucosal veins
● Hypoalbuminemia: Albumin is synthesized in the liver
and thus liver disease causes hypoalbuminemia.
● Coagulopathy
Liver is the site of synthesis of clotting factors, coagulation
inhibitors, and fibrinolytic proteins. Therefore, the most
common coagulation disturbances occurring in liver
disease include thrombocytopenia and impaired humoral
coagulation.
● Hepatopulmonary syndrome: It is characterized by the
triad of abnormal arterial oxygenation caused by
intrapulmonary vascular dilatations (IPVDs) in the setting
of liver disease, portal hypertension, or congenital
portosystemic shunts.
● Hepatorenal syndrome, HRS is a life-threatening medical
condition that consists of rapid deterioration in kidney
function in individuals with cirrhosis or fulminant liver
failure.
● Hepatic Encephalopathy: It describes a spectrum of
potentially reversible neuropsychiatric abnormalities seen
in patients with liver dysfunction and/or portosystemic
shunting.
● Hepatocellular carcinoma:
Hepatocellular carcinoma (HCC) is a primary tumour of the
liver that usually develops in the setting of chronic liver
disease, particularly in patients with cirrhosis and chronic
hepatitis B virus or hepatitis C virus infection.
Nursing Management :

Nursing Assessment

● Assess vital signs. Patient can have fever with chills, hypotension, or tachycardia.

● Review serum sodium and potassium levels, which may become depleted with nasogastric suctioning or fluid shifts.

● Review serial WBC count and differentiation to evaluate the course of action.

● Assess tissue perfusion. Note level of consciousness, skin color and temperature, pulses, and capillary refill.

● Assess hydration status: note skin turgor on inner thigh or forehead, condition of buccal membranes, and development
of oedema or crackles.
● Assess the patient’s abdomen for resolution of rigidity, rebound tenderness, and distention. Auscultate bowel sounds.

Nursing Diagnosis

● Ineffective breathing pattern related to increased abdominal distension.

Intervention –

1. To provide oxygen therapy.

2. To perform nebulization.
3. To advice to do spirometry .
4. To provide semi- fowler poition .
5. To monitor SPo2 level .

● Impaired nutritional status related to anorexia and underlying disease condition.

1. To advice to take small and frequent diets .

2. To monitor intake and output .

3. To give health education .

● Fluid volume excess related to intravascular fluid shift to the peritoneal space and edema.

1. To administer diuretics as adviced.

Activity intolerance related to fatigue, lethargy and malaise secondary to disease condition.

1. To assess the level of activity intolerance.

2. To assist physiotherapist in doing active passive exercises and chest physiotherapy.
3. To administer supplemental vitamin therapy to the patient .
4. To provide high calorie and high protein diet.

Nurse’s Progress Notes:

Date and Day Condition of Patient

Day 1 ● Vital signs of the patient recorded carefully.
07/11/2023 ● Hygiene of the patient is well maintained.
Tuesday ● Patient’s hemodynamic parameters charted on hourly basis.
● Paracentesis was assisted.
● Medication administration done as per the orders by the doctor.
Day 2 08/11/2023 ● Vital signs of the patient recorded carefully.
Wednesday ● Hygiene of the patient is well maintained.
● Medication administration done as per the orders by the doctor.
● Maintained intake-output hourly chartings.
Day 3 09/11/2023 ●Vital signs of the patient recorded carefully.
Thursday ● Hygiene of the patient is well maintained.
● Medication administration done as per the orders by the doctor.
● Maintained intake-output hourly chartings.
● Bed bath given and all dressings changed under aseptic conditions.

Health education :-
DIET: Low salt, high protein, normal diet is recommended for the client. Following foods are recommended:

● Whole grains in the form of bran, whole wheat bread or cereal, brown rice, whole grain pasta or porridge, whole oats,
wild rice, rye, oatmeal and corn.
● Fruits and vegetables

● Olive oil, canola oil and flaxseed oil

● Healthy proteins in the form of low-fat milk, dairy products along with lean meats, beans, eggs and soy products

● Low fat dairy products: milk, yogurt and cheese.

● High fiber foods such as vegetables, fruits, nuts, legumes (beans, peas and lentils), whole- wheat flour and wheat bran.
● Foods containing monounsaturated and polyunsaturated fats includes avocados, almonds, pecans, walnuts, olives, and
canola, olive and peanut oils (Lower cholesterol levels)

b) PHYSICAL ACTIVITY AND EXERCISE

Under the guidance of a physiotherapist, the client performs diaphragmatic breathing exercises, coughing exercises,
spirometry, passive ROM exercises. He also goes for walk with the assistance of nursing personnel and GDAs.

c) MEDICATIONS

Health education regarding his pharmacological management given (name of the drug, dose, route and precautions that
needs to be taken) and clarified his doubts.

d)Teach about Hand washing:

Practice good hand washing techniques. Encourage any family and friends who are in contact with client to practice good
hand washing techniques. Wash hands well before caring for any wounds or doing any dressing changes. Report any
changes in the wound (increased redness, swelling, or drainage).

Contacts: Avoid close contact with people who have obvious illnesses such as colds and flu. Avoid crowds, particularly
when in a closed area, during cold and flu season or when you are highly immunosuppressed. Do not share eating
utensils, cups, and glasses with others since many viral illnesses are spread through saliva and mucous. Do not share
razors or toothbrushes.

Conclusion:
I Himani Sangwan student of M.Sc. Nursing 1st year was posted in private Ward, from 06/11/23-10/11/23. There I took
this patient Mr. Vishnu Kant , 34 years old for my case study and is a known case of CLD NASH. The patient was admitted
with complaints of ascites, weight gain, swelling over legs. I gave him care for 3-4 days care while preparing for this case
study and I came to know the disease condition and correlate it with the book clinical manifestation, diagnostic
evaluation and Treatment. On my last day of patient care the patient's condition was stable.

Bibliography:
1) Lippincott, manual of nursing practice, edition 8th publisher Jaypee brothers Pp. 1075- 1077.

2) Brunner & Suddarth’s, Medical Surgical Nursing. 10th Edition: Pp-1113-1116.

3) PubMed:http://www.pubmed.org

4) Joyce M. black, eighth edition, volume 2, Medical surgical nursing.