Objectives

General Objectives:
After

the presentation the participants will be able to understand the nursing care of Liver Cirrhosis.

Objectives
Specific Objectives: Present the demographic profile, history of present illness, laboratory examination, and other pertinent assessment of the patient

Objectives

Specific Objectives:
Correlate

the findings of assessment results to the pathophysiology of the disease

Objectives

Specific Objectives: Identify the drugs and mechanism of action used by the patient

Objectives

Specific Objectives: Derive the nursing consideration in administering medication

Objectives

Specific Objectives:
Identify

the most effective nursing care plan for the patient

Samar
November 14, 1949

Mrs. X Female
May 2, 2011

61 y/o

SOCIAL/LIFESTYLE HISTORY

SOCIAL/LIFESTYLE HISTORY

SOCIAL/LIFESTYLE HISTORY

SOCIAL/LIFESTYLE HISTORY

PAST MEDICAL HISTORY

Childhood Illness Fever, cough and colds Adult Illness high blood pressure. Immunization no longer remembered.

PAST MEDICAL HISTORY

Previous Hospitalization

Olphi Hospital February 19, 2011 Jose Reyes Memorial Medical Center May 2, 2011

Operation Bilateral Tubal Ligation 1981 Injuries None Allergies No known allergies on foods and medications. Medication taken 2 days prior to confinement Paracetamol and Kremil-S tablets

HISTORY OF PRESENT ILLNESS

February 15, 2011

severe stomach ache, head ache, dizziness and loss of appetite. itchiness and easy fatigability. Paracetamol and Kremil-S tablets

HISTORY OF PRESENT ILLNESS

February 19, 2011, 12pm

severe

stomach ache Hematemesis loss of consciousness. to Olphi Hospital in Samar.

X-ray, ECG, UTZ confined for 4 days. 1 unit of PRBC monitored for blood glucose level.

HISTORY OF PRESENT ILLNESS

February 23, 2011,

discharge

from the hospital Omeprazole and Metronidazole were prescribed.

HISTORY OF PRESENT ILLNESS

One day prior to admission,

nothing

per orem in preparation for endoscopy.

Prior to admission
severe

stomach ache hematemesis loss of consciousness.

Physical Assessment
GENERAL APPEARANCE HEAD TO TOE ASSESSMENT

General Appearance

State of Awareness and level of consciousness:

Conscious,

alert and responsive to questions and answers appropriately.

General Appearance

Apparent state of health

chronically

ill : progressive signs and symptoms:

enlargement

of the abdomen (ascites), with grade 2 pitting edema and yellowish discoloration of the skin (jaundice) and itchiness around skin (pruritus).

General Appearance

Signs of distress by verbalizing

nahihirapan

na akong huminga at kumilos

Head to Toe Assessment

Parts of the Body Actual Findings Interpretation
decrease blood flow of bile to the intestine for digestion. Therefore, there is marked accumulation of bile together with bilirubin in the liver. Blood then reabsorb bilirubin and distributes it to the systemic circulation. This, yellowish discoloration is present.

Integument Color

Yellowish color of skin. Grade 2 pitting edema on feet.

Thin and dryness appearance of skin

Head to Toe Assessment

Parts of the Body
Head Face Eyes

Actual Findings
With wrinkles,

Interpretation
Wrinkles and sagged facial skin indicates muscle atrophy due to aging process. Pale palpebral conjunctiva may be caused by decreased oxygen carrying capacity of the blood. Marked accumulation of the bile together with the bilirubin in the liver. Blood then reabsorbs bilirubin and distributes to the systemic circulation. Thus, yellowish discoloration is present.

Pale-yellowish colored sclera and palpebral conjunctiva. Yellowish in color

Ears

Head to Toe Assessment

Parts of the Body Actual Findings Head Yellowish color, Nose with flaring. Mouth Lips Pale in appearance. Gums Yellowish in color. Teeth Missing teeth (26 adult teeth only) Palates and Yellowish color Uvula Interpretation

Head to Toe Assessment:

Parts of the Body Thorax and Lungs Posterior Thorax Actual Findings
Decreased chest expansion (<3cm) Decreased chest expansion (<3cm) Vein is visible

Anterior Thorax

Heart and Central Vessels Jugular Veins

Head to Toe Assessment

Parts of the Body Peripheral Vascular System Peripheral pulses Actual Findings
Decreased or weak thread pulsation Yellowish discoloration Dull sounds are heard Liver cannot be assessed due to pain upon palpation with a pain scale of 8/10.

Abdomen

Head to Toe Assessment

Parts of the Body Extremities Upper and Lower Actual Findings
Peripheral grade 2 edema on feet Decreased muscle mass Limited movement; patient cannot do full range of motion without assistance.

Gordon's Functional Health Patterns

Gordon's Functional Health Patterns

HEALTH PERCEPTION-HEALTH MANAGEMENT PATTERN The patient verbalized satisfaction on the current health situation compared to the pain and difficulties she experienced before she was admitted to JRMMC. Shows interest in improving health situation.

Gordon's Functional Health Patterns

NUTRITIONAL-METABOLIC PATTERN
She

usually eats 3 cups of rice per day with some fish, vegetables and meat. On nothing per orem for 2days due to gross hematemesis of 500ml. height= 52, weight= 145lbs and BMI=26.5. Visible weight increase of 6lbs due to accumulation of fluids within the body. Notable drying of skin with pitting edema of grade 2 in both lower extreme ties

Gordon's Functional Health Patterns

ELIMINATION PATTERN Mrs. X usually has bowel movement of 1x/day before she was admitted to the hospital, but this changed during her stay in the hospital.1500cc, Output: 300cc with notable tea colored urine. No bowel movement for 3 days.

Gordon's Functional Health Patterns

SLEEP REST PATTERN
Mrs.

X usually sleeps at 8:00 pm and wakes up at 4:00 am. This pattern changed when she was admitted although she was able to sleep at night, whenever she wakes up she feels like she is not rested well. Dark circles around the eyes, frequent yawning during the interview. Observed to be sleeping most of the time during the day. Notable irritability when waken up.

Gordon's Functional Health Patterns

COGNITIVE-PERCEPTUAL PATTERN
The

client has clear speech pattern. She had difficulty of recalling recent information. She was oriented to time, place and person.

Gordon's Functional Health Patterns

SELF-PERCEPTION AND SELF-CONCEPT PATTERN The patient appears anxious on the outcome of her conditions. Her eyes appears teary. Mild anxiety is noted.

Gordon's Functional Health Patterns

ROLE-RELATIONSHIP PATTERN She noted that sometimes she had quarrels with her husband but its easily resolved. Noticeable excitement and smiles during our interview about her family.

Gordon's Functional Health Patterns

SEXUALITY-REPRODUCTIVE PATTERN
Lack

of privacy to the environment was verbalized by the client and was observed.

Gordon's Functional Health Patterns

COPING-STRESS TOLERANCE PATTERN
She

mentioned that in the past when she feels stressful the only thing she does is to go out, watch TV or sleep. Present signs of stress such as teary eyes, sudden movements of hands and quivering of voice are noted.

Gordon's Functional Health Patterns

VALUE-BELIEF PATTERN
Patient

verbalized hope and belief in the support system and health care team by.

LABORATORY EXAMINATIONS
COMPLETE BLOOD COUNT HEMATOLOGIC SECTION

COMPLETE BLOOD COUNT

Test
Hemoglobin

Normal Values
170-180

Result
94.0

Interpretation
Decreased hemoglobin level indicates anemia from recent acute bleeding Decreased; indicates anemia, acute blood loss from bleeding Decreased: indicates Anemia from recent acute bleeding

Hematocrit

0.40-0.54

0.30

Red Blood Count

4.6-6.2

3.48

COMPLETE BLOOD COUNT

Test
MCHC

Normal Values
33-36

Result
32

Interpretation
Decreased: indicates Iron Deficiency Anemia Increased: indicates Infection, Inflammation, Trauma Increased: indicates Acute Stress Response, Acute infection

White Blood Count

5-10

10.48

Neutrophils

55.0

84.8

COMPLETE BLOOD COUNT

Test Lymphocytes Normal Values
34.0

Result 8.1

Interpretation
Decreased: indicates infection
Increased: signs of Allergic reactions Decreased; indicates decreased blood clotting factor

Eosinophils

3.0

6.4

Platelets

150-450

110

HEMATOLOGIC SECTION
Test Prothrombin time Normal Values 11.3-15.3 Result 19.3 Interpretation Increased: Indicates a high chance of bleeding, clotting factor depletion

PATHOPHYSIOLOGY

Non-Modifiable -Age (40-60 y/o)

Drugs alcoholism systemi toxins infection virus c s

Alteration in physiologic function

Nutritional metabolism

Fibrosis

Death

Nursing Care Plan

Fluid volume excess related to accumulation of fluid in peritoneal cavity
Imbalanced nutrition less than body requirements related to inadequate diet, discomfort and anorexia Altered comfort related to itchiness as evidenced by dryness of the skin

ASSESSMENT
Subjective: Ang bigat ng tyan ko as verbalized by the patient.
Objective: presence of edema in lower extremities DOB RR 32 cpm Abdominal girth 93cm Intake-1500cc Output-300 cc/ 8 hrs Weight: 148 lbs. Height- 52

NURSING DIAGNOSIS

Fluid volume excess related to accumulation of fluid in peritoneal cavity

PLANNING
Short Term: After 8 hours of nursing intervention the client will able to improve fluid volume excretion as evidenced by: decrease of 3cm in abdominal girth. Long Term: After 24 hours of nursing intervention the client will able to improve fluid volume excretion as evidenced by: -Increased urine output -decreased ascites with decrease in weight

INTERVENTION
Independent: Measure and record abdominal girth and weight Monitor VS and I and O Explain rationale for Na and fluid restrictions Dependent: Administer diuretics as ordered Instruct about restrictions of sodium and fluid intake to less than 1 Liter/day

EVALUATION
Short Term: After 8 hours of nursing intervention the client was able to improve fluid volume excretion as evidenced by: decrease in abdominal girth. Long Term: After 24 hours of nursing intervention the client was able to improve fluid volume excretion as evidenced by: Increased urine output decreased ascites with decrease in weight

ASSESSMENT
Subjective: Nanghihina ako at laging nahihilo. as verbalized by the patient. Objective: Anorexia weight- 148 lbs height- 52 eats 3x a day, in small amount cup of rice. poor appetite feeling of discomfort headache

NURSING DIAGNOSIS

Imbalanced nutrition less than body requirements related to inadequate diet, discomfort and anorexia

PLANNING
Short Term: After 8 hours of nursing intervention the client will able to: shows desire to eat each served Long Term: After 3 days of my nursing intervention, the client will able to demonstrate improvement of nutritional status as evidenced by increased food intake

INTERVENTION
Independent: encourage patient to eat, small frequent feeding encourage to eat high calorie and high in carbohydrate diet. Encourage frequent mouth care, especially before meals.
Dependent: Administer Vitamins, Zinc supplements as ordered

EVALUATION
Long Term: After 3 days of my nursing intervention, the client was able to demonstrate improvement of nutritional status. Short Term: After 8 hours of nursing intervention the client showed desire to eat each serve meals

ASSESSMENT

Subjective: Nangangati at pansin ko naninilaw and buo kung katawan as verbalized by the patient. Objective: feeling of discomfort pruritus (itching) along with dryness of the skin irritability scratching of skin

NURSING DIAGNOSIS

Altered comfort related to itchiness as evidenced by scratching of the skin

PLANNING
Long Term: After 4-8 hours of nursing intervention the client will have: maintenance of skin and mucous membrane integrity Short Term: Within 3 hours of rendering nursing care, the clients itching will be controlled as evidenced by: client feels some relief. decreased dryness of skin decreased in scratching

INTERVENTION
Independent: Wash skin with warm water and mild soap Instruct to wear loose, soft clothing Keep linens dry and free of wrinkles. Soft bed linens and change soiled linen as much as possible. Suggest clipping fingernails short Dependent: -Administer medication
diphenhydramine (Benadryl), as ordered

EVALUATION
Long Term: After 4-8 hours of nursing intervention the client was able to: maintenance of skin and mucous membrane integrity Short Term: Within 3 hours of rendering nursing care, the clients itching was controlled as evidenced by: client feels some relief. decreased dryness of skin decreased in scratching

DRUG STUDY
Name of Drug
Generic Name: Furosemide Dosage: 40 mg

Side Effect
headache, paresthesis, weakness, hypotension,

Nursing Consideration - Monitor blood pressure before giving the drug. - Monitor fluid intake and output - Watch out for signs of hypokalemia

DRUG STUDY
Name of Drug Generic name: Paracetamol

Side Effect

Nursing Consideration

Dosage: 300 mg/iv

A fever with chills or a Monitor the temperature sore throat of the patient Sores, white spots in Do not exceed to 10 the mouth and lips, and doses within 24 oral ulcers hours as it may give Skin rashes or hives strain to the liver. unusual bleeding or Advice relative that drug bruising has also been is only for short term reported. use.

DRUG STUDY
Name of Drug Generic Name: Vitamin K

Side Effect
Pain, swelling, and tenderness at the allergic sensitivity (i.e., rash, urticaria), including an anaphylactoid reaction

Nursing Consideration
Assess for any allergy to the drug. Check for medical history especially blood disorders, liver diseases Monitor for the Prothrombin time.

Dosage: 1 ampule

DRUG STUDY
Name of Drug Generic Name Side Effect Headache Diarrhea Fatigue Constipation Nausea abdominal pain Nursing Consideration Assess for any allergy to the drug

Omeprazole

Dosage:

40 mg

DRUG STUDY
Name of Drug Side Effect Nursing Consideration

Generic Name: Propanolol

Dose: 50mg

Nausea Diarrhea, Bronchospasm, Dyspnea Cold extremities

Monitor blood pressure of the patient Watch out for side effects