A CASE STUDY ON LIVER CIRRHOSIS

SECONDARY TO NON-ALCOHOLIC
FATTY LIVER DISEASE,
CHOLEDOCHOLITHIASIS
Prepared by:

Aca, Bulawan O.
Amora, Dimple Jasmine
Andoy, Marylit
Burgos, Kate Aenyle A.
Barbac, Hannah
Canda, Joseph Emmanuel
Carlos, James Raphael
Abstract (this will be 4% of your total grade)
• This is a case study of a 69-year-old woman is a known of
Non-Alcoholic Fatty Liver Disease (NAFLD) progressing
to Liver Cirrhosis that admitted at Northern Mindanao
Medical Center. A comprehensive assessment was done in
order to create a vision of the disease process. From risk
factors, etiology, and pathophysiology of the diseases was
vigorously being formulated to determine the cause of the
disease. Diagnostic and laboratory evaluations were
carefully studied as significant to the disease process and
drug study which provide information of the medications.
Importantly, emphasizing the gerontology nursing and
establishing nursing care to the patient were built through
this study. A pragmatic Nursing Care Plan were formed to
in accordance to the immediate health needs of the patients.
Abstract (this will be 4% of your total grade)
• The researchers were able to identify the key contributors to the
present status by understanding the pathophysiology of the disease.
From this, both appropriate medical and nursing intervention were
derived. This study contribute to the nursing profession both in the
clinical area and the academe. Management of patient with Liver
Cirrhosis secondary to Non-Alcoholic Fatty Liver Disease with and
some similar conditions of liver problems can still be improved.

Keywords: Non-Alcoholic Fatty Liver Disease, Liver Cirrhosis,

Ascites, Abdominal girth, Peritoneal Dialysis, Diuretics
Table of Contents
(Part of the 3% of your grade- falls under formatting)
• Make sure that the pages are correct and
matches the content of the case study.
• On the next page, you must include the “List
of Tables”.
• On the next page, you must include the “List
of Figures”.
Acknowledgments
The group would like to extend their deep gratitude to the
following people who played an important role in the success and
completion of this case study:
First of all, to our Almighty God for giving us wisdom,
knowledge, guidance, love, and strength that really helped the
group throughout the process of making our study. Despite the
challenges and hardships that the group faced, He still gives us the
light that we will be able to finish this study with success.
To the group’s clinical instructor, Mr. Josileo Bonzo, RN, for his
guidance, understanding, and patience and for sharing his
knowledge with the group so the group can learn in this field of
study
Acknowledgments
To our Dean, Dr. Fidela B. Ansale, RN, MAN, for her
continuous reminder and for her full support to her
students that inspire us to be more focused and give our
all in making our case study.
To the staff of Northern Mindanao Medical Center
Medical Ward for helping us to achieve our goals for
the improvement of this case study by giving us help
and a positive approach.
The group offers the success and completion of our
case presentation to these people. Without them, we
will not be enlightened to complete this study.
Introduction
Background of the Study
• Patient X is a 69-year-old female, who was admitted at
Northern Mindanao Medical Center last March 31, 2023 with
chief complained of abdominal distention as the reason for
hospitalization. She was later diagnosed of having Liver
cirrhosis secondary to non-alcoholic fatty liver disease.
Introduction
Background of the Study

• Non-alcoholic fatty liver disease (NAFLD) is a chronic

liver disease that is caused by the accumulation of fat in the
liver. The treatment of NAFLD involves managing the
underlying causes of the disease, such as obesity, metabolic
syndrome, type 2 diabetes, and high blood pressure. The
main medical knowledge and techniques used in treating
NAFLD include lifestyle modifications, such as weight
loss, regular exercise, and dietary changes, are important in
managing NAFLD.
Introduction
Background of the Study

• Non-alcoholic fatty liver disease (NAFLD) is becoming a

leading cause of liver cirrhosis worldwide, and there is
currently significant research being conducted to better
understand the disease and develop effective treatments.
Some of the current developments in the world related to
liver cirrhosis secondary to NAFLD include research into
new treatments: There is ongoing research to develop new
treatments for NAFLD and liver cirrhosis.
Introduction
Background of the Study

• The group decided to choose this case as one of the unusual

terms for a lay person, thus it is rarely encountered in the
ward by a student nurse. Acquisition of cognitive knowledge
regarding the topic would enable the researchers in providing
optimum care for clients suffering and in delivering
appropriate intervention that would promote health and
wellness for the client. The group gathered up researchers
about Liver Cirrhosis secondary to non-alcoholic fatty liver
disease to bring knowledge about the signs and symptoms,
diagnostic test and management of the said disease. This will
serve as a guiding tool in proper management of disease.
Introduction
Objective of the Study
• This case study is aimed at exploring the disease process, and the
medical-surgical and nursing management of liver cirrhosis
secondary to non-alcoholic fatty liver disease,
choledocholithiasis. At the end of this case study, the researchers
will be able to trace the pathophysiologic process of liver
cirrhosis secondary to non-alcoholic fatty liver disease,
choledocholithiasis, integrate its medical-surgical management
into the nursing process, and systematically identify the priority
nursing problems to come up with comprehensively developed
care plans and discharge instructions.
Introduction
Objective of the Study (4% of your grade)
• Example:
• This case study is aimed at exploring the disease
process, and the medical-surgical and nursing
management of dengue hemorrhagic fever. At the
end of this case study, the researchers will be able to
trace the pathophysiologic process of dengue
hemorrhagic fever, integrate its medical-surgical
management into the nursing process, and
systematically identify the priority nursing problems
to produce comprehensively developed care plans
and discharge instructions.
Introduction
Significance of the Study
Nursing Practice
This case study can be used as a tool in nursing practice because it
provides nursing interventions for patients with Liver Cirrhosis
secondary to non-alcoholic. This study can give a good introduction
to the disorder so that an established nursing action can be quickly
utilized and through discovering and rediscovering, and trial after
trial of interventions and facilitation of this condition, more
advanced nursing management may be developed. Through this
study, important information regarding this illness has been gathered
which will be helpful for the researchers to have an in-depth
understanding of the said disorder. This study will be able to
generate information that will give the staff nurses in the Medical
Ward the opportunity to identify the determinants of care in the
ward and able to gain insights into the areas that need refinement.
Introduction
Significance of the Study (4% of your grade)
Nursing Education
• This study can be a useful learning guide in nursing education as
this can be used as a reference for future studies regarding Liver
Cirrhosis secondary to non-alcoholic liver disease and related
cases. This case study will enable the students to learn how to
assess patients with Live Cirrhosis and be able to provide
appropriate nursing care and management.
• The students will learn about the nursing interventions and have
an idea of the rationale behind their actions. They can apply these
interventions in a real setting when they encounter the same or
similar condition. In this way, they are acquiring more knowledge
about the disease that they can use to further develop their skills
as student nurses and future nurses.
Introduction
Significance of the Study
• It may open a new door in the practice of getting
quality care and will refine the student’s clinical
reasoning and interpersonal skills in the health care
setting. Nursing educators will be the ones to
evaluate the clinical areas that need improvement
and be able to produce strategies for having a
conducive learning environment.
Introduction
Scope and Delimitation
• This study focuses on the patient’s diagnosis of liver
cirrhosis secondary to non-alcoholic fatty liver
disease, choledocholithiasis, along with its
manifestations, and treatment plans using the
resources that the researchers have acquired. This
study includes all information about the patient’s
condition and medical-surgical-nursing management
that took place only within the limits of the nursing
care instituted by the group between April 2, 2023 to
April 18, 2023.
Introduction
Definition of Terms
• Define ONLY the variables and the medical-surgical
procedures involved in your case study.
• NOT ALL medical terminologies need to be defined. DO
NOT define any medical diagnosis.
Introduction
Definition of Terms
• Cirrhosis - a condition in which your liver is scarred and
permanently damaged. Scar tissue replaces healthy liver tissue
and prevents your liver from working normally. Scar tissue also
partly blocks the flow of blood through your liver. As cirrhosis
gets worse, your liver begins to fail.
• Peritoneal Dialysis Insertion - Peritoneal dialysis (PD) is a
procedure that can be used by people whose kidneys are no
longer working effectively. It does not cure or treat the underlying
kidney disease. It is intended to replace as many functions of the
failing kidneys as possible. The procedure is performed at home
and primarily works to remove excess fluid and waste products
from the blood.
Introduction
Definition of Terms
• Cirrhosis - a condition in which your liver is scarred and
permanently damaged. Scar tissue replaces healthy liver tissue
and prevents your liver from working normally. Scar tissue also
partly blocks the flow of blood through your liver. As cirrhosis
gets worse, your liver begins to fail.
• Peritoneal Dialysis Insertion - Peritoneal dialysis (PD) is a
procedure that can be used by people whose kidneys are no
longer working effectively. It does not cure or treat the underlying
kidney disease. It is intended to replace as many functions of the
failing kidneys as possible. The procedure is performed at home
and primarily works to remove excess fluid and waste products
from the blood.
Introduction
Definition of Terms
• 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.
• Bariatric and Metabolic Surgery - the most effective and long-
lasting treatment for severe obesity resulting in significant weight
loss and the improvement, prevention or resolution of many
related diseases including type 2 diabetes, heart disease,
hypertension, sleep apnea and certain cancers.
Patient's Profile
Demographic Profile (4% of your grade)
• Carefully describe the biographic data of your patient, while
being extra cautious in maintaining patient privacy.
• DO NOT mention the name (not even the last name) of the
patient in part of this case study. Doing so will violate the
patient’s right to data privacy.
• When mentioning the address of the patient, provide only the
barangay or the municipality, the city, and the province.
• Do NOT provide specific identifiers that may violate data
privacy. These include email addresses, phone numbers, social
security numbers, birthdates etc.
• DO NOT include the picture of your patient.
• The demographic profile may include the patient’s age, address
(Not too specific), year of birth, nationality, religion, marital
status, educational attainment, occupation and source of
income, among others.
Patient's Profile
Nursing Health History (4% of your grade)
• Thoroughly discuss the findings of your subjective assessment
which focuses on the following:
1. History of Present Illness (including the chief complaint)
• Describe the chief complaint using COLDSPA- Character,
Onset, Location, Duration, Severity, Pattern, Associated
factors.
2. Past Health History
3. Family History
• Ask the patient for any presence of medical condition of
his/her relatives from both maternal and paternal side,
such as hypertension, diabetes, asthma, cancer, epilepsy,
psychosis, etc).
4. Lifestyle (ie., Alcohol, Illicit Drug use, Risk Taking activities
etc.)
Patient's Profile
Nursing Health History (4% of your grade)
• It is highly recommended that your nursing health history includes
additional information guided by the following (Just remember the
mnemonic “SAMPLE”):
• Symptoms- “What brought you to the hospital?”
• Allergies- “Are you allergic to anything? What happens if you
are exposed to something that you are allergic to?”
• Medications- “Are you currently taking any medications?
What for?”
• Past medical history- “Did you have this problem before?
What other health problems do you have?”
• Last Oral Intake- “When did you last eat or drink anything?
What was the last food/drink you consumed?”
• Events- “What led to this injury? What do you think happened
that led to this problem?”
Patient's Profile
Vital Signs
• Specify both the
1.) vital signs taken during the patient’s admission
2.) vital signs during the period when the patient is under your care.
• You may also include periods when the patient is not
under your care, but the vital signs are remarkably
abnormal (this might provide a supporting data for
the disease pathophysiology).
• Highlight ALL abnormal vital signs in RED FONT.
• Your vital signs must indicate the date and time when
it was taken, focusing on the Temperature, Pulse
Rate, Respiratory rate, Blood Pressure and Oxygen
Saturation.
Patient's Profile
Physical Assessment (Based on Gordon's Functional Health Assessment) (8% of your
grade)
• Your physical assessment must be guided and
organized according to Gordon’s Functional Health
Patterns (Refer to your RLE Assessment Form):
1.) Health perception and health management pattern
2.) Nutritional-metabolic pattern
3.) Elimination pattern
4.) Activity and exercise pattern
5.) Sleep and rest pattern
6.) Cognitive and perceptual pattern
7.) Self-perception and self-concept pattern
8.) Roles and relationships pattern
9.) Sexuality and reproduction patterns
10.) Coping and stress tolerance pattern
11.) Value- belief pattern.
Patient's Profile
Physical Assessment (Based on Gordon's Functional Health Assessment) (8% of your
grade)

• Be very thorough in your assessment.

• Common mistakes in the health/physical assessment include:
• Failure to describe the characteristics (odor, color, clarity) of
the patient’s urine.
• Failure to describe the characteristics (odor, consistency,
shape, color & amount) of the patient’s stool.
• Failure to specify the amount of the patient’s urine per shift
(or within the 24-hour period).
• Failure to describe the patient’s bowel sounds and measure
the patient’s abdominal girth.
• Failure to describe the level of patient’s activity tolerance,
range of motion, mobility, and ambulation.
Patient's Profile
Physical Assessment (Based on Gordon's Functional Health Assessment) (8% of your
grade)
• Common mistakes in the health/physical assessment include:
• Failure to describe the patient’s sexual activities, use of contraceptives,
ability to achieve sexual satisfaction, and menstrual cycle (if the patient is
female).
• Failure to include the patient’s visual acuity, eye color, clarity of the
patient’s sclera and cornea, color of the patient’s conjunctiva and PERRLA
assessment.
• Having assessment findings that do NOT match the patient’s sex and age.
• Example:
• A 63-year-old male patient having an open fontanel.
• A 2-year-old patient who experienced menopause at age 43.
• A 23-year-old male patient who had menarche at age 13.
Patient's Profile
Physical Assessment (Based on Gordon's Functional Health Assessment) (8% of your
grade)

• Patient's Developmental Stage

• Discuss the patient’s developmental stages according to the
following:
• Sigmund Freud’s Psychosexual Development
• Erik-Erikson’s Psychosocial Development
• Jean Piaget's Stages of Cognitive Development
• Lawrence Kohlberg's Stages of Moral Development
Theoretical and Conceptual Framework
(4% of your grade))
• Carefully explain your chosen nursing
theory. Comprehensively describe the
theory and explain the assumptions of
your selected theory.
• The nursing theory that you selected
must have assumptions and
propositions that carefully match the
situation of your patient.
• DO NOT just copy-paste from the
internet.
• You must carefully explain how your
chosen theory fits your case study,
and how the analysis of your study
will be guided by your chosen theory.
Theoretical and Conceptual Framework
(4% of your grade))
Examples:
• Katherine Kolcaba’s Theory of Comfort (1994) assumed that
human beings strive to meet, or to have met, their basic comfort
needs. This theory is suited for patients who are experiencing
pain and discomfort.
• Huemer Uy and Daisy Palompon’s Filial Care Theory (2021) is
particularly applicable for older adults who have been neglected
by their children. The theory assumes that filial care is the
fulfillment of the children’s mutually implied caring duty to
ensure their parent’s survival, wellbeing, and integrity. The
theory further proposes that caring behaviors toward older
persons can be learned and unlearned. This theory can be used
as basis in encouraging younger family members (particularly
children) to take an active role in caring for their older family
member who has special health needs.
Anatomy and Physiology (2% of your grade)

• DO NOT just copy-paste from the internet.

• You must carefully explain how the function of each
body part is essential in understanding the disease
process of your patient.
Diagnostic and Laboratory Tests
(4% of your grade)

• Carefully enumerate and explain ALL the diagnostic and

laboratory procedures undergone by the patient throughout
the duration of his/her hospital confinement.
• Pro Tip: In certain situations, especially when the
patient has already been confined for a long period, the
patient may have more than one hospital chart.
• You must make sure that you have reviewed all records
that are pertinent to the patient’s current confinement.
• If you noticed some missing diagnostic and laboratory
test results, you must consult your instructor, or the
staff assigned to your patient.
Diagnostic and Laboratory Tests
(4% of your grade)

• Include the results of all diagnostic and laboratory

procedures that you can obtain from the patient’s chart.
• DO NOT include images of the patient’s Xray, Ultrasound,
ECG, etc. However, you still need to copy and explain the
physician’s impression and interpretation of those images.
• For the laboratory procedures (i.e., Complete Blood Count,
Urinalysis, etc.), you must have separate columns for a.) the
test results; b.) the unit of measurement; c.) the normal
values; d.) the interpretation, and e.) the implications. Do
not forget the implications!
• Pro Tip: The “interpretation” column only identifies
whether the test result is high (above normal), normal,
or low (below normal). The “implication” column
explains what the abnormal value would mean, what
caused such abnormality and how it would affect the
patient’s body.
Pathophysiology (12% of your grade)
• Carefully explain the disease process of the
patient—starting from the predisposing and
precipitating factors.
• Pro Tip: Per our college standards, the
“Precipitating Factors” are modifiable and those
that are within the control of the patient. The
“Predisposing Factors” are non-modifiable, and
those that are beyond the patient’s control.
Pathophysiology (12% of your grade)
• Schematic Diagram
• In your schematic diagram, meticulously include ALL the
following components:
1.) All events in the patient’s disease process
2.) The abnormal physical assessment findings
3.) The abnormal laboratory values that are pertinent to the
patient’s case
4.) The abnormal diagnostic findings
5.) The medications prescribed to (and taken by) the patient
6.) All medical and surgical procedures that were undergone
by the patient
7.) Your priority nursing diagnosis
8.) Your preventive nursing interventions (i.e., Performing
tepid sponge bath to prevent further elevation of
temperature).
9.) Possible complications if not alleviated
10.) Perpetuating Factors
Pathophysiology (12% of your grade)
• Note: Perpetuating factors maintain the disabling
symptoms. It refers to any condition or factors, either
in the personal, family or community level that
exaggerate the problem rather than solve it.
• Example:
• Non-compliance to medication regimen would
lead to uncontrolled hypertension.
• Failure to seek immediate medical
consultation for breast irregularities would
lead to detection of breast cancer at the late
stage.
• Failure to follow dietary advice would lead to
consistently high blood sugar levels in
uncontrolled diabetes mellitus.
Pathophysiology (12% of your grade)
• Each component must be represented by a different
shape and color, according to its type.
• DO NOT forget to include a legend in your schematic
diagram.
• For example:
• The medications taken by the patient can
represented by a blue rectangle.
• Abnormal diagnostic and laboratory findings
can be represented by a pink square.
• Possible complications can be represented by
a red triangle.
• Your nursing interventions can be represented
by a green rectangle.
• The perpetuating factors can be represented
by a yellow rectangle.
Pathophysiology (12% of your grade)
• Make sure that all components of your schematic diagram are
connected to one another using lines. Make sure that your lines are
definitive and the relationship between the components are clear.
• Continuous Straight Lines are used if both components are
directly connected or if they have already occurred.
• Broken Lines are used if the connection between both
components is still uncertain, or if a certain component still
has not occurred.
• For example:
• A possible complication of poorly managed diabetes
mellitus is kidney damage. Since kidney damage still
has not occurred to your patient, kidney damage can be
connected using broken lines.
• A possible complication of multiple organ failure is
death. But since your patient is alive, you can include
death as a possible complication of the disease, but you
must use broken lines to connect them.
Pathophysiology (12% of your grade)
• Narrative Form
• Carefully explain your schematic diagram narratively
in such a way that the entire disease process and its
medical-surgical-nursing management can be
understood without looking at the diagram.
• Make sure that ALL the components included in your
schematic diagram are thoroughly explained in your
narrative.
Medical and Surgical Management
Medical-Surgical Procedures (4% of your grade)
• Ideal Procedures
• Do extensive research. By reviewing related literature about the disease process,
explore the latest treatment modalities (both medical and surgical) which may be
applicable to your patient.
• Use reputable scholarly journals and published scholarly sources as your reference.
• Avoid citing from unreputable websites. Use www.scholar.google.com to search for
journals and scholarly articles related to your topic.
Medical and Surgical Management
Medical-Surgical Procedures (4% of your grade)
• Actual Procedures
• Extensively discuss both the medical and surgical management of your patient.
• Kindly use the following questions to guide you in discussing the medical-surgical treatment
modalities:
• What is the treatment/procedure all about?
• Is it medically necessary? If so, why is it necessary?
• What part of the disease process is the treatment/procedure intended to resolve/prevent?
(Refer to your pathophysiology discussion)
• What is the success rate of the procedure? (Or how effective is the treatment/procedure?)
• What are the possible complications of the treatment/procedure?
• How did your patient respond after undergoing the treatment/procedure?
Drug Study #1

1.) Generic name

• propranolol
2.) Brand Name
• Oranol.
3.) Dosage
• 10 mg
4.) Timing
• BID- (8AM & 6PM)
5.) Route
• Oral
Drug Study
6.) Mechanism of Action
Propranolol is a nonselective β-adrenergic receptor antagonist.2 Blocking of
these receptors leads to vasoconstriction, inhibition of angiogenic factors like
vascular endothelial growth factor (VEGF) and basic growth factor of fibroblasts
(bFGF), induction of apoptosis of endothelial cells, as well as down regulation of
the renin-angiotensin-aldosterone system.

7.) Indications
Although once used to treat hypertension, coronary artery disease, and
atrial fibrillation, propranolol is now used mainly to reduce the chance of
variceal bleeding in patients with liver cirrhosis. It lowers the risk of variceal
bleeding by decreasing cardiac output and splanchnic blood flow.

8.) Contraindications
Asthma, COPD, Severe sinus bradycardia or 2°/3° heart block (except in
patients with functioning artificial pacemaker), Cardiogenic shock,
Uncompensated congestive heart failure, Hypersensitivity, Overt heart failure,
Sick sinus syndrome without a permanent pacemaker.
Drug Study
9.) Adverse Effects (Side Effects)
CNS: fatigue, weakness, anxiety, dizziness, drowsiness, insomnia, memory loss,
mental depression, mental status changes, nervousness, nightmares. EENT:
blurred vision, dry eyes, nasal stuffiness.
Resp: bronchospasm, wheezing.
CV: ARRHYTHMIAS, BRADYCARDIA, CHF, PULMONARY EDEMA,
orthostatic hypotension, peripheral vasoconstriction.
GI: constipation, diarrhea, nausea.
GU: erectile dysfunction, decreased libido.
Derm: itching, rashes.
Endo: hyperglycemia, hypoglycemia (increased in children).
MS: arthralgia, back pain, muscle cramps.
Neuro: paresthesia.
Misc: drug-induced lupus syndrome.
Drug Study
10.) Nursing Responsibilities
 Assess heart rate, ECG, and heart sounds, especially during exercise.
 Report immediately an unusually slow heart rate (bradycardia) or signs
of other arrhythmias, including palpitations, chest discomfort, shortness
of breath, fainting, and fatigue/weakness.
 Assess blood pressure (BP) periodically and compare it to normal
values to help document antihypertensive effects. Assess BP when the
patient assumes a more upright position (lying to standing, sitting to
standing, lying to sitting).
 Do not abruptly discontinue the medication
 Compliance with the therapy regimen is essential to control
hypertension, arrhythmia, and anginal pain.
Drug Study #2

1.) Generic name

• lactulose
2.) Brand Name
• Duphalac
3.) Dosage
• 30cc
4.) Timing
• OD (8pm)
5.) Route
• Oral
Drug Study
6.) Mechanism of Action
Constipation: Hyperosmotic agent increases stool water contents,
softens stool, promotes peristalsis, and reduces blood ammonia
concentration.

7.) Indications
⮚ Prevention, and treatment of portal-systemic encephalopathy
(including hepatic pre-coma, and coma); treatment of constipation. It is also
indicated to reduce the amount of ammonia in the blood of patients with liver
disease. It works by drawing ammonia from the blood into the colon where it is
removed from the body.
Drug Study
10.) Nursing Responsibilities
 Assess patient for abdominal distention, presence of bowel sounds, and
normal pattern of bowel function.
 Assess color, consistency, and amount of stool produced.
 Encourage adequate fluid intake.
 Monitor daily pattern of bowel activity and stool consistency; record
time of evacuation.
 Assess for abdominal disturbances. Monitor serum electrolytes in
patient’s with prolonged, frequent, and excessive use of medication.
 Evacuation occurs within 24–48 hrs of the initial dose. Institute
measures to promote defecation
Drug Study #3

1.) Generic name

• spironolactone
2.) Brand Name
• Aldactone
3.) Dosage
• 100mg
4.) Timing
• BID (8am-6pm)
5.) Route
• Oral
Drug Study
6.) Mechanism of Action
Aldosterone antagonist with diuretic and antihypertensive effects;
competitive binding of receptors at aldosterone-dependent Na-K exchange
site in distal tubules results in increased excretion of Na+, Cl-, and water
and retention of K+ and H+.
Increases testosterone clearance and estradiol production; blocks
conversion of potent androgens to weaker ones in peripheral tissues.

7.) Indications
Management of edema associated with excessive aldosterone excretion or
with HF; hypertension; cirrhosis of the liver with edema or ascites,
hypokalemia, nephrotic syndrome, severe HF; primary hyperaldosteronism.
OFF-LABEL: Treatment of edema, hypertension in children, female acne, and
female hirsutism.
Drug Study
8.) Contraindications
Hypersensitivity, Addison disease or other conditions associated with
hyperkalemia, Coadministration with eplerenone.

9.) Adverse Effects (Side Effects)

These common side effects of spironolactone happen in more than 1 in 100
people. There are things you can do to help cope with them:
- Feeling dizzy
- Feeling or being sick
- Muscle or leg cramps
- Feeling tired or low in energy
- Breast pain and breast enlargement, including in men Serious side effects
Drug Study
10.) Nursing Responsibilities
 Weigh pt; initiate strict I&O.
 Evaluate hydration status by assessing mucous membranes, and skin
turgor
 Obtain baseline serum electrolytes, renal/hepatic function, and
urinalysis.
 Assess for abdominal disturbances. Monitor serum electrolytes in
patient’s with prolonged, frequent, and excessive use of medication.
 Assess for edema; note location, and extent
 Check baseline vital signs, note pulse rate/regularity
 Expect an increase in the volume, and frequency of urination.
 The therapeutic effect takes several days to begin and can last for
several days when the drug is discontinued.
Drug Study #4

1.) Generic name

• tramadol
2.) Brand Name
• Agoram
3.) Dosage
• 50mg
4.) Timing
• PRN (as needed)
5.) Route
• Oral
Drug Study
6.) Mechanism of Action
Non-opioid-derived synthetic opioid; centrally acting analgesic, but
may act at least partially by binding to opioid mu receptors, causing
inhibition of ascending pain pathways.

7.) Indications
Management of moderate to moderately severe pain. Extended-Release:
Around-the-clock management of moderate to moderately severe pain for an
extended period.
Drug Study
8.) Contraindications
Hypersensitivity to tramadol or opioids. Known or suspected
gastrointestinal obstruction, including paralytic ileus. Concurrent use of
monoamine oxidase inhibitors (MAOIs) or use within the last 14 days.

9.) Adverse Effects (Side Effects)

Headaches, Feeling sleepy, tired, dizzy or "spaced out", Feeling or being
sick (nausea or vomiting), Constipation, Dry mouth, Sweating, Low energy.
Drug Study #5

1.) Generic name

• furosemide
2.) Brand Name
• Fusedix
3.) Dosage
• 40mg
4.) Timing
• BID (8am and 6pm)
5.) Route
• Oral
Drug Study #6

1.) Generic name

• furosemide
2.) Brand Name
• Fusidex
3.) Dosage
• 40mg
4.) Timing
• BID (8am and 6pm)
5.) Route
• Oral
Drug Study
6.) Mechanism of Action
Loop diuretic; inhibits reabsorption of sodium and chloride ions at
proximal and distal renal tubules and loop of Henle; by interfering with the
chloride-binding cotransport system, causes increases in water, calcium,
magnesium, sodium, and chloride.

7.) Indications
Treatment of edema associated with HF and renal/hepatic disease; acute
pulmonary edema. Treatment of hypertension, either alone or in combination
with other antihypertensives.
Drug Study
8.) Contraindications
• PO/IV/IM
- Documented hypersensitivity to furosemide or sulfonamides
- Anuria
• SC on-body infusor
- Documented hypersensitivity to furosemide or sulfonamides
- Anuria
- Hepatic cirrhosis or ascites

9.) Adverse Effects (Side Effects)

Peeing more than normal, Feeling thirsty, Dry mouth, Headaches, Feeling
confused or dizzy, Feeling or being sick (nausea or vomiting).
Drug Study
10.) Nursing Responsibilities
 Check vital signs, esp. B/P, pulse, for hypotension before
administration.
 Assess baseline serum electrolytes, esp. for hypokalemia.
 Assess skin turgor, and mucous membranes for hydration status;
observe for edema.
 Obtain baseline weight. Initiate I&O monitoring.
 Monitor B/P, vital signs, serum electrolytes, I&O, and weight.
 Note the extent of diuresis.
 Expect increased frequency, and volume of urination.
 Hypokalemia may result in changes in muscle strength, tremors, muscle
cramps, altered mental status, and cardiac arrhythmias; hyponatremia
may result in confusion, thirst, and cold/clammy skin.
Drug Study #7

1.) Generic name

• zinc sulfate syrup
2.) Brand Name
• Orazinc
3.) Dosage
• 10ml
4.) Timing
• OD
5.) Route
• Oral
Drug Study
6.) Mechanism of Action
Zinc inhibits cAMP-induced, chloride-dependent fluid secretion by
inhibiting basolateral potassium (K) channels, in in-vitro studies with rat
ileum.
7.) Indications
To treat or prevent low levels of zinc alone and together with oral
rehydration therapy (ORT).
Drug Study
8.) Contraindications
Contraindicated in: Hypersensitivity or allergy to any components in
formulation; Pregnancy or lactation (supplemental amountsRDA for pregnant or
lactating patients); Preparations containing benzyl alcohol should not be used in
neonates.Use Cautiously in: Renal failure.

9.) Adverse Effects (Side Effects)

Breathing in zinc sulfate can irritate the respiratory tract, and cause nausea,
vomiting, stomach ache, dizziness, depression, metallic taste in the mouth, and
death.
Drug Study
10.) Nursing Responsibilities
 Monitor progression of zinc deficiency symptoms (impaired wound
healing,growth retardation, decreased sense of taste, decreased sense of
smell) during therapy.
 Monitor serum alkaline phosphatase concentrations monthly; may
increase with zinc therapy.
 Monitor HDL concentrations monthly in patients on long-term high-
dose zinc therapy. Serum concentrations may be low.
 PO:Administer oral doses with food to decrease gastric irritation.
 Encourage patient to comply with diet recommendations of health care
professional.
 Explain that the best source of vitamins is a well-balanced diet with
foodsfrom the four basic food groups.
 PRIORITY PROBLEM #1: Excess Fluid Volume related to

Nursing
compromised regulatory mechanism secondary to cirrhosis of
the liver as manifested by abdominal distention

Management • Subjective Cues:

• > “nabantayan gyud nako nga ga dako gyd akong tiyan” as
verbalized
• Objective Cues:
> Abdominal distention noted
> Decreased urine output @ 200-240 cc/day
> Abdominal girth of 104.5 cm
> Elevated BUN @ 28.3
 • Goals and Objectives
Nursing
Management Short Term Goals:
• After 6 hours of nursing intervention, patient will demonstrate
behaviors to monitor fluid status and reduce recurrence of fluid
excess.
Long Term Goals:
• After 2 days of nursing intervention, patient will be able to maintain
a balance in fluid volume with fluid and sodium restriction.
 • Nursing Interventions
Independent:
Nursing 1. Monitor vital signs
r: to established baseline data.
Management 2. Evaluate total daily intake. Maintain daily of input and output.
r: to reveal changes that should be made in client’s dietary intake.
3. Monitor abdominal girth
r: reflects accumulation of fluid.
4. Monitor BP.
r: BP elevations are usually associated with fluid volume excess.
5. Weigh the patient daily at the same each day.
r: daily body weight is best monitor of fluid status.

Dependent:
1. Restrict sodium and fluids as ordered.
r: sodium may be restricted to minimize fluid retention in
extravascular spaces.
 • Nursing Interventions
Nursing 2. Administer medications as indicated: Spironolactone, Furosemide

Management r: used with caution to control edema and ascites, block the effect of
aldosterone, and increase water excretion while sparring potassium.

Collaborative:
1. Review medical regimen
r: to provide information/assistance as necessary
Evalutaion
• Goals partially met.
• After 2 days of nursing intervention, the patient was able to
demonstrate behaviors to monitor fluid status and reduce recurrence
of fluid excess.
 • PRIORITY PROBLEM #2: Imbalance nutrition: less than body
requirements related to loss of appetite
Nursing • Subjective Cues:

Management > “makakaon rakog 3-4 ka kutsara nga lugaw sir.” as verbalized
• Objective Cues:
> Loss of appetite
> Abdominal distention noted; girth @104.5 cm
> Weight loss
 • Goals and Objectives
Nursing
Management Short Term Goals:
• After 5 hours of nursing intervention, patient’s appetite will improve
from 3 tbsp to at least 5 tbsp per meal.
Long Term Goals:
• After 2 days of nursing intervention, patient will demonstrate healthy
eating pattern.
 • Nursing Interventions
Nursing Independent:
1. Monitor vital signs
Management r: for baseline data
2. Discuss eating habits including food preferences.
r: to stimulate appetite.
3. Recommend small, frequent meals
r: poor tolerance to larger meals may be due to increased intra-
abdominal pressure/ ascites.
4. Restrict intake of caffeine, gas-producing or spicy and
excessively hot or cold foods.
r: aids in reducing gastric irritation and abdominal discomfort that
may impair oral intake/digestion.
 • Nursing Interventions
Nursing Independent:
5. Provide assistance with activities as needed. Promote
Management undisturbed rest periods, especially before meals.
r: conserving energy reduces metabolic demands on the liver and
promotes cellular regeneration.
6. Limit foods that induce nausea or vomiting
r: these measures may be helpful in increasing food intake.

Dependent:
1. Provide nutriotional supplements as appropriate or ordered.
r: to further strengthen the body.
 • Nursing Interventions
Nursing Collaborative:

Management 1. Discuss with MD the potential need for referral to a dietitian.

r: to individualize the patient’s plan of care regarding nutrition.

Evalutaion
• Goals not met.
• After 8 days of nursing intervention, the patient was not able to
improve her appetite and not able to demonstrate healthy eating
pattern.
 • PRIORITY PROBLEM #3: Activity Intolerance related to
generalized body weakness
Nursing • Subjective Cues:

Management > “luya kaayo e lihok akong lawas sir.” as verbalized

• Objective Cues:
> Difficulty initiating movements
> ADLs level status @ 2 (assist with person)
> Decreased ROM
> Decreased HGB level
 • Goals and Objectives
Nursing
Management Short Term Goals:
• After 8 hours of nursing intervention, the patient will participate
willingly in necessary activity.
Long Term Goals:
• After 2 days of nursing intervention, patient will be able to conserve
energy and verbalize relief from fatigue.
 • Nursing Interventions
Independent:
Nursing 1. Evaluate patient’s current activity tolerance.

Management r: provide cooperative baseline.

2. Adjust activity and reduce intensity of task that may cause
undesired physiological changes.
r: to prevent over exertion.
3. Increase exercise and activity levels gradually.
r: enhances activity tolerance
4. Demonstrate/ Assist the patient while doing ADL
r: to protect patient from injury.
5. Teach methods to conserve energy such as sitting than
standing while dressing.
r: helps minimize waste of energy
 • Nursing Interventions
6. Encourage client to do whatever possible e.g self-care
Nursing r: provides for sense of control and feeling of accomplishment

Management Dependent
1. Assess the need for ambulation aids (e.g cane, walker)
r: assistive devices enhance the mobility of the patient by helping her
overcome limitations.

Collaborative
1. Provide referral to other disciplines as indicates (e.g physical
therapies and occupational therapies).
r: to develop individually appropriate therapeutic regimens.
 • Nursing Interventions
Nursing Evaluation

Management • Goals partially met.

• After 8 hours of nursing intervention, the patient was able to
participate in treatment regimen/activities
 Goals:
Discharge Upon discharge the patient will be able to:
Plan * Fully comprehend on the prognosis of related condition
* To understand further home management and therapies to provide
appropriate care as needed
* To help the patient and significant other in preventing occurrence of
complications and support restorative process of the patient’s condition.
* Fort the patient’s family to provide emotional and psychological
support to the patient during the post-hospitalization phase.
 Goals:
Discharge Upon discharge the patient will be able to:
Plan * Fully comprehend on the prognosis of related condition
* To understand further home management and therapies to provide
appropriate care as needed
* To help the patient and significant other in preventing occurrence of
complications and support restorative process of the patient’s condition.
* Fort the patient’s family to provide emotional and psychological
support to the patient during the post-hospitalization phase.
 Medication:
Discharge Your provider will give you a list of your medicines when you leave the
hospital.
Plan * Know your medicine. Know what they look like, how much you
should take each time, how often you should take them, and why you
should take each one.
* Take your medicine exactly as your provider tells you to.
* Carry a list of your medicines in your waller or purse include any
nonprescription medicine and supplements on the list.
>Your provider may prescribe medicine to:
> Treat or prevent and infection
> If you have had surgery, to care for your wound:
• - Keep your wound clean.
 Medication:
Discharge • If you are told to change for change your dressing on your infection,
wash your hands before changing the dressing and after disposing of
Plan the dressing. And after disposing of the dressing
Activity:
• Unless you are told otherwise
• Avoid lifting, pulling or pushing any heavy objects (more than 10
pounds). For the first 3 days after discharge.
• Avoid straining or any activity in which you hold your breath and
exert yourself or “bear down,” such as when having a bowel
movement or lifting yourself upp, ask your physician about a laxative
or stool softener if you become constipated.
• Do not drive for the first 3 days after discharge
• If you have any questions or concerns, please ask your physician or
your nurse.
 • You may take a warm tub bath but avoid using very hot water

Discharge • Talk with your physician before returning to work. This varies with
each patient and depends on your work and its demands

Plan Diet
• Reduce sodium intake: Patients with liver cirrhosis often have fluid
retention and swelling, so it's important to limit their sodium intake
to less than 2,000 milligrams per day.
• Increase protein intake: The liver plays a key role in protein
metabolism, and patients with cirrhosis may have trouble processing
protein. However, they still need to consume enough protein to
maintain muscle mass and prevent malnutrition. The recommended
daily protein intake is about 1.2 to 1.5 grams per kilogram of body
weight.
• Avoid alcohol: Alcohol can further damage the liver and worsen
cirrhosis. Patients with liver cirrhosis should avoid all alcoholic
beverages.
 • You may take a warm tub bath but avoid using very hot water

Discharge • Talk with your physician before returning to work. This varies with
each patient and depends on your work and its demands

Plan Diet
• Eat small, frequent meals: Patients with liver cirrhosis may
experience a decreased appetite or feel full quickly. Eating small,
frequent meals can help them get the nutrients they need without
feeling overwhelmed.
A healthy lifestyle:
• Stop drinking alcohol: Alcohol is one of the leading causes of
cirrhosis, so it's important to avoid it completely.
• Follow a healthy diet: Patients with cirrhosis should follow a healthy
diet that is low in salt and saturated fat, and high in protein, fiber, and
nutrients.
 • Exercise regularly: Regular exercise can help improve muscle
strength, reduce the risk of complications, and improve overall
Discharge health. Patients should aim for at least 30 minutes of moderate
exercise, such as walking or cycling, on most days of the week.
Plan • Manage stress: Stress can worsen cirrhosis symptoms and increase
the risk of complications. Patients should try to manage stress
through techniques such as relaxation exercises, meditation, or
counseling.
• Hygiene:
• Wash hands frequently: Encourage the patient to wash their hands
frequently, especially before eating or touching their face, and after
using the bathroom or being in contact with someone who is sick.
• Keep the home clean: Make sure the patient's home is clean and free
of dust, mold, and other allergens that can worsen their symptoms
and increase the risk of infections.
 • Practice good oral hygiene: Patients with cirrhosis may have an
increased risk of gum disease, so it's important to encourage them to
Discharge brush their teeth twice a day, floss regularly, and visit the dentist for
regular check-ups.
Plan • Avoid sharing personal items: Encourage the patient to avoid sharing
personal items such as razors, toothbrushes, or towels with others to
reduce the risk of infections.
Spiritual teachings
• Provide care by simply asking patient how you can support them
based on their religion and beliefs
• Encourage patient to continiosly do religious practices like praying if
that that will help them feel better.
• Advice the client’s family to use their gifts of presence and touch as
it boosts their sense of belongingness
 Results and Discussion
• The researchers were able to compare the actual and ideal nursing and
medical intervention to the patient’s condition. Not only did we assess the
patient’s condition during the days of the assessment process, but we also
included the patient’s immediate family members, specifically his mother who
was there the entire time. Emotional aspects in their well-being were assessed
as well since it is stated that nursing care is not limited to the care of the
patient but also includes the care of the significant others. For such patients
and family is a single unit of care.
• Based on the study, there are various medical interventions that can be
done to facilitate complete recovery of the patient’s condition. There are also
things that will help and allow the patient to recover without having
complications. Thus, there are gaps between ideal and actual medical-surgical
interventions. This is the reason why nursing care should be focused before
and during the hospital stay of the patient.
Conclusion
• In conclusion, this case study explored the disease
process, and the medical-surgical and nursing
management of liver cirrhosis secondary to non-
alcoholic fatty liver disease, choledocholithiasis.
The researchers were able to trace the
pathophysiologic process of liver cirrhosis
secondary to non-alcoholic fatty liver disease,
choledocholithiasis, integrate its medical-surgical
management into the nursing process, and
systematically identify the priority nursing
problems to come up with comprehensively
developed care plans and discharge instructions.