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A case study on cirrhosis of liver


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case study on liver cirrhosis

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A case study on cirrhosis of liver

  1. 1. OObbjjeeccttiivveess ooff CCaassee ssttuuddyy  TToo ggaaiinn iinn--ddeepptthh kknnoowwlleeddggee aabboouutt tthhee ssttuuddyy ssuubbjjeecctt//ddiisseeaassee ccoonnddiittiioonn..  TToo ggaaiinn tthhee ccoonnffiiddeennccee iinn hhaannddlliinngg ssuucchh ccaasseess iinn ffuuttuurree..  TToo ffuullffiillll tthhee ppaarrttiiaall ccoouurrssee oobbjjeeccttiivvee ooff MM..NN.. ccuurrrriiccuulluumm..  To share experience and knowledge to friends,juniors and seniors. Rational for the selection of case  Cirrhosis is ranked as the 9th leading cause of death in the united state and 4th leading cause of death in person between 35 and 45 years of life.  Excessive alcohol injection is the single most common cause of cirrhosis and alcoholism is common in Nepalese society, that’s why it is the interesting case for study so, I select this case. A CASE STUDY ON CIRRHOSIS OF LIVER Health History: A: Bio-graphicalData: Patient’s Name : - Mrs. Thumi Sara Marsagni Age/ sex :-75 yrs/female Marital status : - Married Education : - Literate Occupation : - Agriculture Religion : - Hind Address :- Nawalparasi, Gaidakot ,1 Ward :- Female Medical Ward Bed No. : - 31 IP No. :- 45697 Date of admission :- 2068/07/13 Provisional Diagnosis:- Cirrhosis of Liver Interview date :- 2068/07/14 Date of discharge :- 2068/07/18
  2. 2. Final Diagnosis :- Cirrhosis of Liver Attending physician :- Informants Obtained From :- Patient (self)& his son B : Chief complain  Abdominaldistention since 15-16 days  Bilateral pedal swelling since 10-12 days  Moderate shortness of breathing since 5-7 days  Loss of appetite since 15-16 days C. PresentIllness/Health Status 1. Summaryof Presentillness; Mrs . Thumisara was absolutely fine before 17monts back. Gradually she developedthe problems ofabdominal distension,swelling of lower legs and mild to moderate shortness of breathing, so her family members tookher in medical shop near by her home and she was referred to hospital for further management . at that time she attained the medical OPD and cirrhosis of liver was diagnosed and advised to take oral medicines and stop of alcohol . Her condition was gradually improved. Thumisara again started to take alcohol since 6-7 months and the problem was relapsed again and she was admitted. 2. Investigationof symptom symptoms onset character duration Alleviating factors Aggravating factor Abdominal distention 15- 16days moderate _ _ While taking more fluids and alcohol Bilateral pedal swelling since 10-12 days moderate _ _ _
  3. 3. shortness of breathing 5-7 days Mild to moderate _ Abdominal distention Resting in upright position Loss of appetite since 15-16 days moderate _ _ _ D.Past Illness: Childhood Illness Adult Illness 2) Injuries andAccidents: My patient had no any history of external injuries and accidents. 3) Hospitalization, Operations or Special Treatment: she had no history of previous hospitalization , but she had treated in OPD with same problembefore 17 months. 4) Allergies:-According to my patient she has not known allergies to any food, Drugs and others Diseases yes No Disease Yes No Measles  Hypertension  Mumps  Heart disease  Whooping cough  Tuberculosis  Polio  Diabetes  Rheumatic Fever  Filariasis  Tuberculosis  Malaria  Malnutrition  Cancer  operation  Asthma  Others Accidents  Others 
  4. 4. 5) MedicationTakenat Home :- She uses to takes some home remedy like Juwano, ginger , besar , marcha for some common health problem. 6) Traditional Healer’s Prescription: According to my patient, sometimes shealso used to take the Traditional Healer’s prescriptions for her and her family’s health problems. 7) Medical Practioner’s prescription:- According to my patient, she takes medical practioner’s prescription for his health problem. 8)Self prescription:My patient useto take some common medicines like , paracetamol, Decold , Diagen in her family members’ prescription whenever she has problem like headache ,fever , common cold , etc. but they doesn’tknow the drug doses, it’s side effect ,indication and contraindications etc. Family History 1) No. of children Age(year) Health Status Krishna Bahadur Marsagni 48 years Healthy Pashupati Marsangi 46 years Healthy Drupati Marsangi 42 years Healthy Dol Kumari Marsangi 39 years Healthy Bharat Marsangi 37 years Healthy 2) History of Any of the Disease belowinMother’s andFather’s Family Disease Father’s Family Mother’s Family Remarks yes No yes No Hypertension   Diabetes   Cancer   Blood disorder   Asthma   Cardiovascular problems   Arthritis/Gout  
  5. 5. Tuberculosis   Other specify   FAMILY TREE F. Psychological: a) Client’s Reaction to illness: Mrs . Thumisara, has normalreaction to her illness . b) Client’s Coping Pattern: she is using her pastexperiences of illness, other life experiences and supportfrom the family, relatives as well as health person as coping pattern. c) Client’s Value of Health: she thinks that health is very essential for young age but have to maintain for lifelong as we can. d) Client’s Perception of the Care Giver: she thinks that all health care provider arevery kind. 75 years 42 yrs yrsyr s 48 yrs 37 yrs 46 yrs 39 yrs
  6. 6. G. Sociological: a) Family Relationship: Client’s Position in the Family: she is the eldest person of the family. Person Living With Client (SupportSystem) : Her Family Members (sons ,daughters granddaughter and grandsons. Recent Family Crisis or Changes: according to informant, they have difficultin managing the time for their sick mother because they have to go for work and study. B) OccupationalHistory: PresentJob: sheis very old ,so she cannot do any work. . c) Educational Level: Highest Degreeor Grade Attended: illiterate Level of Learning: illiterate) Cultural: Ethnic Group: Magar Client’sBeliefsabout Health and Illness: Her beliefs that the illness is caused by the unhappiness by god. Client’s HealthPractice: According to she, she don’thave any idea for good health practice Sources of Care(Modern/traditional): According to her and her informant , sometimes they goes to traditional healer , sometimes they goes to local medical shop and health post as well as Hospital for health seeking. e) Leisure Time Activities: shespends her time with her grandsons and grand- daughters f) Chemical Use (type, frequency, problems relatedtouse) Cigarettes: smoker. Shetakes 3-4 sticks /day Substances (e.g. Hashish, bidi, etc):- Non –user Alcohol: shetakes alcohol every day about 800-1000ml. H. Environmental History:
  7. 7. a) Type of Drainage System: Open b) Types of Toilet Used: Water seal c) Sources of drinking Water: Tap water (unboiled water) ) KitchenStyle: Separate kitchen e) Types of Fuel Usedin Cooking: Fire-Wood I. Significant DevelopmentTask a) Past if Relevant………………………………………………………… b)Current inTerms Of Appropriate Task For Age………….. …………………………………………………………………………………. Developmentaltasks of older adulthood S.N. According to book According to patient 1 Adjusting to decreasing health and physical strength  My patient is adjusting her decreasing health and physical strength as she is depending on stick while walking .  As she is older she cannot do household work so she is depending to her family members for her activities of daily living  She is accepting her decrease health and physical strength as normal phenomena. 2 Adjusting to reduced or fixed income  My patient has no fixed income so she is economically fully depending to her family members . 3 Adjusting to death of spouse  Mrs. Thumisara has already lost her husband for 10 years so she is adjusting to death of spouse 4 Accepting oneself as an aging person  Mrs. Thumisara has full awareness that she is very old and she accepts oneself as an aging personso she
  8. 8. handed over her kingship to her son and daughter- in law 5 Maintaining satisfactory living arrangements  Mrs. Thumisara has not maintained her own satisfactoryliving arrangement because she is non job holder women however she is satisfied whatever she has now. 6 Redefining relationships with adult children.  My patient redefining relationship with adult children as she is still honorable in her family as a head of family so she gives her valuable advice and suggestionto her family as needed. 7 Finding meaning in life.  My patient is accepting the god’s natural phenomena towards the living creature and realizing that she fulfilled her female role sincerely.
  9. 9. Physical Examination S.N HealthHistory (Subjective Data) Ye s No Physical Examination (objective Data) 1 General Cognation(Limitation/Restricti on) Sensation(Limitation/Restricti on) Communication(Limitation/Re striction General Gait: Imbalanced Facial Expression (grimacing): undifferentiated Level of consciousness: Conscious Orientation to time ,place and person: fully oriented Measurements Height: 4feet 6 inch Weight :37 kg Temperature : 98°C Pulse:90 b/min Respiration:20 /min Bloodpressure : 110/60 mmof hg 2 ProblemrelatedtoHeadand face Headache Injury Puffiness of face Hair :black and grey in colour Scalp: dirty, dandruff present, no injury, lumps and other lesions present Skull: normalin shape Face:uniformmovement of side of face , slight edema ,no masses Sinuses : No swelling , tenderness and depression
  10. 10. 3 ProblemRelatedtoEye/ Vision Pain Swelling Discharge Excessive tears Difficulty Seeing at Night Any other problems…………………… Conditionof Eyelids: No swelling, redness ,lesions Conditionof Conjunctiva: pale palpebral conjunctivas, Conditionof cornea:transparent Colour of Sclera: yellow sclera Pupil Size Symmetry: uniformin size and shape Reactiontolight : reactive to light Discharge fromeyes : slightly white sticky discharge Visual Acuity: Sub- Normal Eye Glasses : Not used 4 ProblemRelatedtoEar: Pain Tinnitus Vertigo Dizziness Others ………………….. Conditionof External Ear: Normally Located external Ear Drainage from Ear: No dischargeof pus , blood ,slightly wax present Lumps or Lesions: Notfound Ear Drum: Hearing Aid: Not used Rinne Test: AC>BC Weber Test: AC>BC 5 Problems RelatedtoNose Injury Bleeding /Discharge Blockage Location: centrally located Nasal Deviation: Not found Bleeding: No Patency of the Nostrils: patented Any Discharge: Not found Smell:No problem in smelling Conditionof Nasal mucosa: Pale in colour Flaring Nostrils: Notpresented. Inflammation: Not found. Nasal Polyps: Not found
  11. 11. 6 Problems RelatedtoMouth Sore on Lips Sore on Tongue Gum Bleeding Missing Teeth/Dentures Change inTaste Toothache Lips:Dry Oral Cavity: Pale mucous membraneof oral cavity Teeth: Missing all teeth Tongue: slightly dry and coated tongue Vocal cord, Uvula and Tonsils: Not enlarged and inflamed. 7 Problems RelatedtoSpeech Loss of Consciousness Loss of Memory Convulsion SpeechDisorders: Notpresented. 8 Throat and Neck Difficulty nSwallowing Problems inTonsil Neck Rigidity Location: centrally located, no tilting of head Movement : Full and smooth range of movement, no stiffness or tenderness Jugular Vein: Not enlarged Conditionof Thyroid: No enlargement of thyroid gland ProblemRelatedto Respiration: Dyspnoea Cough Hoarseness of Voice Cyanosis Others……………………………….. Respiratory Rat:20 b/min Depthof respiration: Normaldepth Quality of Respiration :dyspnoea in lying position Chest Inspection - lateral diameter is wider than anterior posterior diameter - sternumis located at the midline - Even expansion of the chestduring breathing No intercostals retraction • Slight cough , but no productive sputum. Chest Palpation
  12. 12. 10 11 Heart and Circulation: Chest pain Numbness Palpitation Fever , chills Bleeding tendencies Others :…………………………………………… …………………………………………… Nutrition/Hydration: Anorexia Nausea/ Vomiting Unusualthirst or hunger Diaphoresis Non Vegetarian Special Diet Food Dislikes Ability to Chew or swallow - No tenderness, lump or depression along the ribs. Percussion - Deep resonantsound heard all over the lungs. Auscultation - Breath sounds areheard in all areas of the lungs. - Inspiration longer than expiration - No , rhonchi, wheezing sound was presented Pulse Rate: Radical: 88b/min Apical: 88 b/min Character of Pulse: Normal Blood Pressure: Right110/60mmof hg Left: 100/60 mmof hg Peripheral Pulse: All present Capillary Refill: 1 second Edema ( e.g. puffy eye) : present Varicosities: Absent Visible External Jugular veins : Absent Systolic or Diastolic Murmur : Absent Body Build: Average Body weight : 37 kg Skin Turgor/Elasticity : Normal Condition of Buccal mucosa : intact
  13. 13. 12 13 Resent change in Weight Eliminationand reproduction: Pain in Urination Change in urine colour Urinary Retention Frequency of Urination Incontinenceof Urine Constipation Diarrhea Passing worms, Mucous Eliminationand Reproduction: Appearanceof Stool Bleeding fromRectum Flatulence Heart Burn Abdominal Pain Dischargefrom Genitalia Pain or Swelling of scrotum Any Unexpected vaginal bleeding Any menstrual Disorder Uterine prolapsed Knowledgeof family planning method Family Planning Device Used Appearanceof Urine : yellowish (concentrated) Appearanceof Stool: Normal Any Enlargement of Liver, spleen: moderately enlarged liver found. Any Masses in Abdomen: Not Found Any tenderness in AboveAres: Tenderness in Rt. Hypocardium Size and shape of abdomen: distended abdomen Shifting dullness: present Distendedabdominal veins :slightly Fluidthrill:present Abdominal girth: 33 inch Enlarges Inguinaland femoralNodes: Not found Bowel sounds: Present Lesion or tumors of Rectal Area: Not found Abnormalities of Genito-Urinary Area: Not found Female- Rectocele and Cystocele: not present Uterine prolapsed : not present Discharge : Not present Other……………………… ………………….
  14. 14. 14 15 Bowel Habits: Regular/ Irregular Pap Smear Test Done Mobility : Difficulty with Ambulation Muscle cramping or Weakness Muscle Pain Back Pain Joint Pain or Swelling Limited Joint Movement Ability to Do ADLS Comfort ,Sleepand Rest: Pain Regular Sleep Pattern Integumentary Hygiene : Non –healing sores Change in Mole Colour Nail Changes Itching Of Skin Sensation Regular bathing Habit Motor Strength and Mobility: slight reduced Enlargement and Stiffness of Joints: Not present Contractures: slightly Present( knee joint) Spinal Deformity: Not Present Range of motion Exercise: Cannot move in full Range Of Motion CANE: use of stick Crutches : Not used Walker : Not used Prosthesis : Not Used Location Of Pain : Rt. Hypochondrium tenderness Discomfortdueto abdominal distention Sleep disturb at night Colour of skin, Texture, Turgor : Normal Pigmentation, Lesion, Tumors: Not found Skin Inflammation : Not present Edema: present(lower legs and abdomen) Rashes : Not present AbnormalNail Conditions: Not present Distribution and Texture of Hair : equally distributed of scalp hair, no,any abnormally distribution in body hair , the texture of hair is soft Touch Sensation: Normally Presented all over the body Enlarged lymph Glands and nodes: Not found
  15. 15. 16 Reflexes Biceps Reflex: present Brachilo radialis: present Triceps Reflex: present Patellar Reflex : present Achilles Reflex: present BabinskiReflex : present( negative) Kerning’s sign : Absent UNIT II - INTRODUCTION TO DISEASE Cirrhosis of liver Introduction • The termcirrhosis was first usedby Rene Laennec (1781-1826) todescribe the abnormal liver color of individuals withalcohol inducedliver disease. • DerivedfromGreek word Kirrhosmeans Yellowish –brown color. Definition: • Cirrhosis is achronic progressive disease of the liver characterizedby extensivedegenerationanddestructionof the liver parenchymal cells.
  16. 16. • Cirrhosis is achronic disease characterizedby replacement of normal liver tissue withdiffuse fibrosisthat disrupts the structure and functionof the liver. • The liver cells attempt toregenerate, but the regenerative process is disorganized, resulting inabnormal bloodvessels andbile duct architecture. • The liver slowly deteriorates andmalfunctions due tochronic injury. Scar tissue replaceshealthy livertissue, partially blocking the flowof blood throughthe liver. Scarring also impairs the liver's ability to: • control infections • remove bacteriaandtoxins from the blood • process nutrients, hormones, anddrugs • make proteins that regulate bloodclotting • produce bile tohelp absorbfats—including cholesterol—andfat-soluble vitamins Incidence: • It is the twelfthleading cause of death, 27,000 deaths eachyear and affects menslightly more thanwomen. • It is the 10th leading cause of deathin the US, with mortality rate of 9.2 deaths per 100,000 populations. • Of those deaths, 45% were alcohol related. Menare more likely than women to have alcoholic cirrhosis.
  17. 17. • Worldwide, post necrotic cirrhosis is the most commonin women. Mortality is higher fromall types of cirrhosis inmenand non whites. CAUSES OF CIRRHOSIS  Alcohol  Chronic viral hepatitis (B or C) Non-alcoholic fatty liver disease  Immune o Primary sclerosing cholangitis o Autoimmune liver disease  Biliary o Primary biliary cirrhosis o Cystic fibrosis  Genetic o Haemochromatosis o α1-antitrypsin deficiency o Wilson's disease  Cryptogenic (unknown) Etiology: Alcohol. • Heavy alcoholfor severalyears cancause chronic injury to the liver and damages. • For women, consuming two to three drinks—including beer and wine per day and for men, three to four drinks per day, can lead to liver damage and cirrhosis. • A common problem in alcoholic is protein malnutrition. Obesity: WHO ,2008, estimatedthat more than 200 million men and close to 300 million womenwere obese, obesityis a common cause of chronic liver disease , 17% of liver cirrhosis is attributable to excess bodyweight. Chronic hepatitis C.
  18. 18. Chronic hepatitis C causes inflammation and damage to the liver over time that can leadto cirrhosis and approximately 20% patient will develop cirrhosis. Chronic hepatitis B and D. • Hepatitis B and D is virus that infects the liver and canlead to cirrhosis, but it occurs only in people who already have hepatitis B. approximate 10%- 20% will develop cirrhosis. Nonalcoholic fattyliver disease (NAFLD). • This is associatedwith obesity, diabetes, protein malnutrition, coronary artery disease, and corticosteroidmedications. • Autoimmune hepatitis. It is causedby the body's immune systemattacking liver cells and causing inflammation, damage, and eventually cirrhosis. Genetic factors – About 70 percent of those with autoimmune hepatitis are female. Diseasesthat damage or destroy bile ducts. • Severaldifferent diseases(cholangitis)candamage or destroy the ducts that carry bile from the liver, causing bile to back up in the liver and leading to cirrhosis. Inherited diseases. • Cystic fibrosis, alpha-1 antitrypsin deficiency, hemochromatosis, Wilson disease, galactosemia, andglycogenstoragediseasesare inherited diseases that interfere the liver function properly, Cirrhosis canresult. Drugs, toxins, and infections. • Drug reactions(Acetaminophen, isonazide, methotrexate) prolonged exposure to toxic chemicals, parasitic infections, and repeatedbouts of heart failure with liver congestion. Types of cirrhosis :
  19. 19. Alcoholic (historically called Laennec’s cirrhosis)cirrhosis: • Also calledmicro nodular or portal cirrhosis and usually associatedwith alcoholabuse. • The first change in the liver from excessive intake is an accumulation of fat in the liver cells;uncomplicated fatty changes in the liver are potentially reversible if the person stops drinking alcohol. If the alcoholabuse continues, widespreadscarformation occurs throughout the liver. Postnecrotic cirrhosis(macro nodular): • Mostcommon worldwide, massive loss of liver cells with irregular patterns of regenerating cells due to complication of viral, toxic or idiopathic (autoimmune) hepatitis. Billiary cirrhosis: is associatedwith chronic billiary obstructionand infection. There is diffuse fibrosis of the liver with jaundice. Cardiac cirrhosis:chronic liver disease results from long-standing, severe right side heart failure with corpulmonale, constrictive pericarditis, and tricuspid insufficiency. Pathophysiology: Liver insult, alcoholingestion, viral hepatitis, exposure to toxin Hepatocyte damage Liver inflammation - ↑WBCs, nausea, vomiting, pain , fever, anorexia, fatigue Alteration in blood and lymph flow • Liver necrosis →liver fibrosis and scarring → portal hypertension - ascities, edema,
  20. 20. - spleenomegaly(Anemia, thrombocytopenia, leucopenia) - Varices (esophagealvarices, hemorrhoids.) ↓ billirubin metabolism – hyperbilirubinemia, jaundice • ↓ bile in gastrointestinaltract – light coloredstool • ↑ urobilinogen – Dark Urine • ↓ vit K absorption- bleeding tendency • ↓ metabolism of protein, carbohydrate, fats→ hypoglycemia, • ↓ plasma protein- ascites andedema ↓androgenand estrogendetoxification(↓ hormone metabolism)- ↑ estrogen and androgens hormone – Gynecomastia,loss ofbody hair, menstrual dysfunction, spider angioma, palmer erythema, testicularatrophy • ↓ ADH and aldesterone detoxificationso ↑ ADH levels - edema • Biochemicalalteration- ↑ AST, ALT levels, ↑ bilirubin, low serum albumin, prolong prothombin time, elevatedalkaline phosphatase. • Liver failure • Hepatic encephalopathy • Hepatic coma • Death Clinical manifestations: Earlymanifestations –  No symptoms in the early stages ofthe disease.  GI disturbances are more common , anorexia, dyspepsia, flatulence, weakness,fatigue, nausea, vomiting, weightloss, abdominal pain and bloating, and change in bowel habit ( diarrhea, constipation).  Abdominal pain, dull and heavy feeling in right upper quadrant or epigastric due to swelling and stretching of the liver capsule, spasmof biliary duct.  Fever, lassitude, weightloss, enlargementof liver and spleen.
  21. 21. Later manifestations: May be severe and result from liver failure and portal hypertension.  Jaundice, peripheral edema and ascities developgradually.  Other late symptoms include skin lesion, hematologicaldisorders, endocrine disturbances, and peripheral neuropathy.  In the advancedstage the liver becomes smalland nodular. Jaundice:  It results from the functional derangementof liver cells and compressionof bile duct by connective tissue overgrowth.  Jaundice occurs as a result of decreasedability to conjugate and excrete bilirubin.  If obstruction of the biliary tract occurs, obstructive jaundice may also occurand usually accompaniedby pruritus. Skin lesion:  Spider angioma ( telangiectasia orspidernavi) are small dilated blood vessels with a bright red centerpoint and spider like branches occurs in nose, cheeks,upper trunk, neck and shoulders.  Palmererythema, a red area that blanches with pressure, is locatedon the palm of the hand.  Both lesions are due to increase estrogenin blood as a result of the damaged liver’s inability to metabolized steroid hormone. Hematologic problem:  Thrombocytopenia, leucopenia, anemia, due to spleenomegaly(back flow of blood from portal vein into the spleen.)  Anemia due to inadequate RBC production and survival, and due to poor diet, poor absorption and bleeding from varices.  Coagulationproblems result from the liver’s inability to produce prothrombin and blood clotting and manifested by hemorrhagic phenomena or bleeding tendencies e.g. epistaxis, purpura, gingival bleeding, heavy menstrual flow. Endocrine problem:
  22. 22.  In men, Gynecomastia, lossofaxillary and pubic hair, testicularatrophy and impotence with loss of libido due to increasedestrogenlevel.  In younger female, amenorrhea may occurand in older, bleeding may occur.  ↑aldosterone hormone may cause sodium waterretention and potassium loss. Peripheral neuropathy:  Probably due to dietary deficiencyof thiamine, folic acid and cobalamin. Clinical manifestations: According to book According to patient 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 Decompensate • Ascites • Jaundice • Weakness  Hepatomegaly  Jaundice (bilirubin total 2.2 mg /dl)  Moderate Ascites  Bilateral pedal edema  Losses of appetite  Abdominal pain  dull and heavy feeling in right upper quadrant  weakness, fatigue, nausea, weight loss  Anemia (pale mucosa,)  Mild shortness of breathing • Ascites • Jaundice • Weight loss
  23. 23. • Muscle wasting • Weight loss • Continuous mild fever • Clubbing of fingers • Purpura (due to decreased platelet count) • Spontaneous bruising • Epistaxis • Hypotension • Sparsebodyhair • White nails • Gonadal atrophy Diagnosisaccording to book • Liver function test : ↑alkaline phosphate, ALT,AST and y – glutamyl transpeptidase ( GGT) • Bloodtest: ↓ total protein, ↓ albumin, ↑ serum bilirubin and glubomin • Prothombin time is prolong • Liver cell biopsy to identify liver cellchanges • Ascites fluid test • Liver ultrasound • CT Scan • Stoolfor occultblood Endoscopy Investigations These are performed to assess the severity and type of liver disease. Severity ■ Liver function.Serum albumin and prothrombin time are the best indicators of liver function: the outlook is poor with an albumin level below 28 g/L. The prothrombin time is prolonged commensurate with the severity of the liver disease . ■ Liver biochemistry.This can be normal, depending on the severity of cirrhosis. In mostcases there is at least a slight elevation in the serum ALP
  24. 24. and serum aminotransferases.In decompensatedcirrhosis all biochemistryis deranged. ■ Serum electrolytes.A low sodium indicates severe liver disease due to a defectin free water clearance or to excess diuretic therapy. ■ Serum creatinine.An elevated concentration 130 mol/ L is a marker of worse prognosis.Inaddition, serum -fetoproteinif 200 ng/mL is strongly suggestive of the presence of a hepatocellular carcinoma. Ultrasound examination. This can demonstrate changes in size and shape of the liver. Fatty change and fibrosis produce a diffuse increased echogenicity. In established cirrhosis there may be marginal nodularity of the liver surface and distortion of the arterial vascular architecture. The patency of the portal and hepatic veins can be evaluated. It is useful in detecting hepatocellular carcinoma. Elastography is being used in diagnosis and follow-up to avoid liver biopsy. ■ CT scan Arterial phase-contrast-enhanced scans are useful in the detection of hepatocellular carcinoma. ■ Endoscopy is performed for the detection and treatment of varices, and portal hypertensive gastropathy. Colonoscopy is occasionally performed for colopathy. ■ MRI scan. This is useful in the diagnosis of benign tumours such as haemangiomas. MR angiography can demonstrate the vascular anatomy and MR cholangiography the biliary tree. Liver biopsy This is usually necessary to confirm the severity and type of liver disease. The core of liver often fragments and sampling errors may occur in macronodular cirrhosis. Special stains are required for iron and copper, and various immunocytochemical stains can identify viruses, bile ducts and angiogenic structures. Chemical measurement of iron and copper is necessary to confirm diagnosis of iron overload or Wilson’s disease. Adequate samples in terms of length and number of complete portal tracts are necessary for diagnosis and for staging/grading of chronic viral hepatitis. Diagnostic Investigations in patient According to Book According to Patient
  25. 25. • Liver function test : ↑alkaline phosphate, ALT,AST and y – glutamyl transpeptidase ( GGT) • Bloodtest: ↓ total protein, ↓ albumin, ↑ serum bilirubin and glubomin • Prothombin time is prolong • Liver cell biopsy to identify liver cellchanges • Ascites fluid test • Liver ultrasound • CT Scan •  Liver function test : SGOT/AST : 187 U/L SGPT/ALT: 88.0 U/L Alkaline Phosphate: 124 IU/L  Totalprotein : 6.4 gm/dl  Albumin : 3.4 gm/dl  Prothombin time: 23.3 sec  INR : 1.8  Bilirubin Total: 2.2mg/dl  Creatinine : 2.0 mg /dl  Haemoglobin: 7.8 gm/dl  WBC : 11,600Mm3  Platelets : 61,000Mm3  USG: findings s/o cirrhosis of Liver, Moderate Ascites Others Investigations of patient Date of investigation According to my patient Normal range 2068/07/13 Hematology Hb :7.8gm /dl WBC:11,600 mm3 Platelets :61,000 mm3 ProthombinTime (test): 23.3sec ProthombinTime (control): 14.0 sec INR : 1.8 Differentialcount Neutrophil- 90% Lymphocyte 10% Esinophil-00 Basophil-00 HB% M-13-15 F-12-14 gm/dl WBC-400O-1100mm3 Platelets 1,50,000- 4,00,000 Prothombin Time (test) 14-16 sec Neutrophil-40-70% Lymphocyte-30-35% Esinophil -1-2% Basophil-0-1%
  26. 26. 2068/07/16 Biochemistry-report Blood sugar (R):129.0 mg/dl Creatinine: 2mg/dl Sodium : 142.7mmol/l Potassium :3.45 mmol/l Total Protein : 6.4 gm/dl Albumin: 3.4 gm/dl SGOT/AST: 187.0 U/L AGPT/ALT:88.0 U/L Alkaline phosphates:124.0 IU /L Blood grouping:’’B’’ positive Bilirubin Total: 2.2 mg/dl Bilirubin Total: 0.8 mg /dl ECG : Normal Sinus rhythm, non specificT wave abnormality Urine RE/ME Colour-light yellow Reaction –Acidic Albumin- Nil Sugar-Nil transparency-Clear Pus Cell-2-4 /HPF RBCs: Plenty Epithelialcells- 3-4 /HPF USG abdomen and pelvis: Finding S/O Cirrhosis of Liver Moderate Ascites Blood sugar (R): 60-180 mg/dl Creatinine: 0.4-1.4 mg/dl Sodium : 135-150 mmol/L Potassium : 3.3-5.5 mmol/L Total Protein :6-8 gm/dl Albumin: 3.5-5.5 gm/dl SGOT/AST: M ˂37 F ˂31 U/L AGPT/ALT ˂40.0 U/L Alkaline phosphates : M- 64 -306 F: 84-306 Up to 15 yrs: <644 Up to 17 yrs : <483 Bilirubin Total: 0.4-1.0 mg/dl Bilirubin Total: 0.1-0.4 ECG : Sinus rhythm Urine R/E:Acidic Appearance:Clear Color: P. yellow WBC:3-5/HPF Epithelial cell: 2-4/HPF USG abdomen and pelvis: Normal scan
  27. 27. 068/07/17 Creatinine: 1.7 mg/dl Platelets :67,000 mm3 Hb : 10.2 gm /dl Platelets :92,000 mm3 Creatinine: 0.4-1.4 mg/dl Platelets 1,50,000- 4,00,000 mm3 Management (According To Book) Medicalmanagement • Monitor for complications: Ascites, bleeding esophagealvarices andhepatic encephalopathyand if occurs manage them accordingly. • Many medicines have been studied, such as steroids, penicillamine (Cuprimine, Depen), and an anti-inflammatory agent (colchicine), but they have not been shownto prolong survival or improve survival rate. • Researchersare studying various experimental treatments for cirrhosis.
  28. 28. Surgicalmanagement • The only surgery that has been proven to improve the chances oflong-term survival is liver transplantation. • About 80-90 percent of people who undergo liver transplantation survive. Maximizeliverfunction: • The diet should be adequate calories and protein (75- 100 gm/day) unless hepatic encephalopathyis present, in which case protein is limited. • Restrictfluid and sodium if edema or fluid retention is present. • Diuretic, thiazide – potassium supplement. • The B vitamins and fat soluble vitamins (A, D, E, K). • Adequate rest is needed to maximize regenerationofliver cells. • Corticosteroidsdrugs to improve liver function in post necrotic cirrhosis. Treat underlyingcause:  if cirrhosis is from heavy alcoholuse, the treatment is to completely stop drinking alcohol.  If cirrhosis is causedby hepatitis C, then the hepatitis C virus is treated with medicine Prevent Infection:  by adequate rest, appropriate diet, avoidance ofhepatotoxic substances. Beta-blockeror nitrate • Forportal hypertension. Beta-blockers canlowerthe pressure in the varices and reduce the risk of bleeding. Gastrointestinalbleeding requires an immediate upper endoscopyto look for esophagealvarices. Complications  Portalhypertension: • The nodules and scartissue can compress hepatic veins within the liver. • This causes the blood pressure within the liver to be high, a condition known as portal hypertension.
  29. 29. • Portalvenous pressure is more than 15mmHg or 20 cm of water. • Is characterizedby ↑venous pressure in the portal circulation, spleenomegaly, large collateralvein, ascites, systemic hypertension, and esophagealvarices. • The common area to form collateralchannels are in the loweresophagus( the anastomosisof the left gastric vein and azygos vein), the parietal peritoneum, rectum. • High pressures within blood vessels ofthe liver occurin 60% of people who have cirrhosis  EsophagealVarices: • EsophagealVarices are a complex of tortuous veins at the lowerend of the esophagealenlargedand swollenas a result of portal hypertension. • 10-30%of UGI bleeding due to rupture of varices. • 80% bleeding due to esophagealVarices. • 20% due to gastric varices.  Peripheral edema and Ascites: • Edema results from decreasedcolloidaloncotic pressure from impaired liver synthesis of albumin (hypoalbuminia) • Ascites is the accumulation of serous fluid in the peritonealcavity. • Protein move from the blood vessels via the largerpore of sinusoids into the lymph space. • When the lymphatic systemis unable to carry off the excess protein and water, they leak through the liver capsule into the peritoneal cavity.  Hepatic encephalopathy: • Hepatic encephalopathyis a neuropsychiatric manifestationof liver damage. • It can occurin any condition in which liver damage causes ammonia to enter the systemic circulation without liver detoxification. • Liver is unable to convert ammonia to urea. The ammonia crossesthe blood brain barrier and produces neurologic toxic manifestations • Clinical manifestations include changes in neurologicaland mental responsiveness, ranging from sleepdisturbances to lethargy to deep coma. • Grading systems are: early stage (stage0 and 1) euphoria, depression,
  30. 30. apathy, irritability, memory loss, confusion, drowsiness, insomnia. • Lactulose , low-protein diet improves symptoms in 75 percent of cases. • Later stages(stage2 and 3) include slow and slurred speech, impaired judgment, hiccup slow and deep respiration, babinski reflex, stage 4 include disorientation to time , place, person.  Hepatorenalsyndrome: • Hepatorenalsyndrome is a serious complicationof cirrhosis characterized by functional renal failure with advancing azotemia, oliguria, and ascites. MEDIAL MANAGEMENT IN PATIENT  Fluid restriction < 1000 ml /Day  Low salt diet  Egg white BD  Monitor Daily Weight and abdominal girth  Advice for Completely stop of alcohol  Inj. Vitamin K 1 amp I/V OD x 3 Days  Arrange and transfuse 2 pint of FFP  Arrange and transfuse 1 pint whole blood.  Inj. Optineurone 1 amp to be added in 5% dextrose Others Supportive Managements  Inj .Taxim 1 gram TDS x 5 days  Tab Lasilactone 1 tab Po OD x 5 days  Tab Pantium 40 mg Po OD x 5days  Tab Tone 100 PO BD x 5 days  Tab Usoliv 300mg PO BD x 5days  Inj. Optineurone 1 amp to be added in 5% dextrose x 3 days Nursing management : Assessment  Assess the client client closelyfor the presence of early manifestations such as :  Hepatomegaly  Carefully check the laboratory data.
  31. 31.  As the disease progresses , assessthe manifestations of complications of cirrhosis such as ascites, portalhypertension or hepatic encephalopathy  History taking: pastand present health history (alcoholintake, medication, infection etc) chief complain sign and symptoms of disease  Physicalexamination  Psychosocialassessment Nursing Diagnosis • Ineffective tissue perfusion related to bleedingtendenciesand varicesthat may hemorrhage Goal • Hemorrhage will be prevented as evidenced by absence ofbleeding, normal vital sign and urine output of at least0.5 ml/kg/hour Interventions : • Assess patient’s condition • Monitor for hemorrhage bleeding from gums, melena, hematuria, hematemasis. • Assess vitalsign for sign of shock • Monitor urine output • Protectpatient from physical trauma to prevent hemorrhage • Avoid unnecessaryinjection and apply gentle pressure after injection. • Instruct the client to avoid vigorous nose blowing, straining with bowel movement. • Provide stoolsoftenerto prevent straining with rupture of varices. • Advice to use soft tooth brush to prevent gum bleeding. Activityintolerancerelated to bed rest, fatigue, lack of energy, and altered respiratory function secondary to ascites. Outcomes The patient will maintain a balance betweenrest and activity as evidenced
  32. 32. by the absence offatigue Interventions: • Assess levelof activity tolerance and degree offatigue, lethargy, and malaise when performing routine ADLs. • Assistwith activities and hygiene when fatigued. • Encourage restwhen fatigued or when abdominal pain or discomfort occurs. • Assistwith selectionand pacing of desired activities and exercise. • Provide diet high in carbohydrates with protein intake consistentwith liver function. • Administer supplemental vitamins (A, B complex, C, and K). Impaired skinintegrityrelated to pruritusfrom jaundiceand edema Goal:‘Decreasepotentialfor pressure ulcer development; breaks in skin integrity’ Interventions: • Assess degreeofdiscomfort related to pruritus and edema. • Note and recorddegree of jaundice and extent of edema. • Keep patient’s fingernails short and smooth. • Provide frequent skin care;avoid use of soaps and alcohol-basedlotions. • Massageevery2 hours with emollients;turn every 2 hours • Initiate use of alternating-pressure mattress or low air loss bed. • Recommendavoiding use of harsh detergents. • Assess skinintegrity every 4–8 hours. Instruct patient and family in this activity. • Restrictsodium as prescribed. • Perform range of motion exercises every4 hours; elevate edematous extremities wheneverpossible. Highrisk for injury related to altered clotting mechanismsand altered level of consciousness
  33. 33. Intervention • Assess levelof consciousness and cognitive level. • Provide safe environment (pad side rails, remove obstacles in room, prevent falls). • Provide frequent surveillance to orient patient and avoid use of restraints. • Replace sharpobjects (razors) with saferterms. • Observe eachstoolfor color, consistency, and amount. • Be alert for symptoms of anxiety, epigastric fullness, weakness, and restlessness. • Testeachstooland emesis for occult blood. • Observe for hemorrhagic manifestations:ecchymosis, epistaxis petechiae, and bleeding gums. • Recordvital signs at frequent intervals, depending on patient acuity (every 1–4 hours). • Keep patient quiet and limit activity. Disturbed body imagerelated to changesin appearance, and role function. Goal:‘Patient verbalizes feelings consistentwith improvement of body image and self-esteem’ Intervention: • Assess changesin appearance and the meaning these changes have for patient and family. • Encourage patientto verbalize reactions and feelings about these changes. • Assess patient’s and family’s previous coping strategies. • Assistpatient in identifying short-term goals. • Encourage andassistpatient in decisionmaking about care. • Identify with patient resources to provide additional support (counselor, spiritual advisor). • Assistpatient in identifying previous practices that may have been harmful to self (alcoholand drug abuse). Fluid volumeexcess related to ascites and edema formation Goal:Restorationof normal fluid volume
  34. 34. Intervention: • Restrictsodium and fluid intake if prescribed. • Administer diuretics, potassium, and protein supplements as prescribed. • Recordintake and output every 1 to 8 hours depending on response to intervention and on patient acuity. • Measure and recordabdominal girth and weight daily. • Explain rationale for sodium and fluid restriction. • Prepare patient and assistwith paracentesis Risk for imbalanced bodytemperature:hyperthermia related to inflammatory process of cirrhosis or hepatitis Goal:Maintenance of normal body temperature, free from infection • Recordtemperature regularly (every4 hours). • Encourage fluid intake. • Apply coolsponges or icebag for elevated temperature. • Administer antibiotics as prescribed. • Avoid exposure to infections. • Keep patient at rest while temperature is elevated. • Assess forabdominal pain, tenderness Ineffective breathing pattern related to ascites andrestriction of thoracic excursionsecondary to ascites, abdominaldistention, and fluid in the thoracic cavity. Goal:Improved respiratory status Intervention  Elevate head of bed to at least30 degrees  Conserve patient’s strength by providing rest periods and assisting with activities.  Change position every 2 hours. Assistwith paracentesis orthoracentesis.
  35. 35.  Explain procedure and its purpose to patient.  Have patient void before paracentesis.  Support and maintain position during procedure.  Recordboth the amount and the characterof fluid aspirated.  Observe for evidence of coughing, increasing dyspnea, or pulse rate. Application of Nursing Theory Virginia Henderson’s independence theory  Henderson defined nursing as , “ the unique function of the nurse is to assistthe individual, sick or well , in the performance of those activities contributing to health or its recovery( or to peacefuldeath ) that he would perform unaided if he had the necessarystrength, will or knowledge. And to do this in such a way as to help him gain independence of such assistanceas soonas possible. The 14 Basic components of Nursing Care 1. Breathe normally. 2. Eatand drink adequately. 3. Eliminate body wastes. 4. Move and maintain desirable postures. 5. Sleepand rest. 6. Selectsuitable clothes-dress andundress. 7. Maintain body temperature within normal range by adjusting clothing and modifying environment 8. Keep the body cleanand well groomedand protect the integument 9. Avoid dangers in the environment and avoid injuring others. 10. Communicate with others in expressing emotions, needs, fears, or opinions. 11.Worship according to one’s faith. 12.Work in such a waythat there is a sense ofaccomplishment. 13.Play or participate in various forms of recreation. 14.Learn, discover, or satisfy the curiosity that leads to normal development and health and use the available health facilities.
  36. 36. ASSESSMENT OF PATIENT ON THE BASIS OF 14 BASIS COMPONENTS 1 Breathe normally.  Patient has difficulty in breathing especiallyin supine position due to ascites 2 Eatand drink adequately.  Patient is taking so limited food  She has loss of appetite  She has restricted fluid intake 3 Eliminate body wastes.  Patient has no problem related to bladder and bowel empty but her serum creatinine levelis high (2.0 gm/dl) 4 Sleep and rest  Patient has disturb sleep  She has discomfort due to ascites 5 Selectsuitable clothes-dress andundress.  Patient has no significantproblems in this area. 6 Maintain body temperature within normal range by adjusting clothing and modifying environment  Patient has sometimes mild fever 7 Keep the body cleanand well groomedand protectthe integument  Patient looks dirty  She has risk for skin breakdowndue to edema 8 Move and maintain desirable postures.  Patient has only imitated mobility 9. Avoid dangers in the environment and avoid injuring others.
  37. 37. patient has no significant problems in these areas as the environment is safe for patient 10. Communicate with others in expressing emotions, needs, fears, or opinions.  Patient is communicating limited to health team members because she has some language problem 11. Worship according to one’s faith. Patient has some problem in this areas becauseshe has no appropriate environment for worship according to ownfaith. 12. Work in such a waythat there is a sense ofaccomplishment. Patient has only limited involvement in activities of daily living 13. Play or participate in various forms of recreation.  she does not seems to interested in recreationalactivities like talking to other patients , and staffs 14. Learn, discover, or satisfythe curiosity that leads to normal development and health and use the available health facilities  She is not interested to learn .She is not curious towards environment NURSING CARE PLAN NURSING DIAGNOSIS  Activityintolerancerelated to bed rest, fatigue, lack of energy, and altered respiratory function secondary to ascites. GOAL  The patient will maintain a balance betweenrest and activity as evidenced by the absence offatigue PLANNING
  38. 38.  Assess levelof activity tolerance and degree offatigue, lethargy, and malaise when performing routine ADLs.  Assistwith activities and hygiene when fatigued.  Encourage restwhen fatigued or when abdominal pain or discomfort occurs.  Provide diet high in carbohydrates with protein intake consistentwith liver function.  Administer supplemental vitamins (A, B complex, C, and K). INTERVENTION  Assessed levelof activity tolerance and degree of fatigue, lethargy, and malaise when performing routine ADLs.  Assistedwith activities and hygiene when fatigued.  Encouragedrestwhen fatigued or when abdominal pain or discomfort occurs.  Encouragedto take diet high in carbohydrates.  Encouragedto take egg white BD  Administered supplemental vitamins B complex, (inj. neurobion in 5% dextrose)as prescribed  Administered vit. K as prescribed Evaluation: My goal was partially met as patient was complained of less fatigue than before. NURSING DIAGNOSIS  Fluid volumeexcess related to ascites and edema formation Goal  Restorationofnormal fluid volume PLANNING  Restrictsodium and fluid intake if prescribed.  Administer diuretics, potassium, and protein supplements as prescribed.  Recordintake and output every 1 to 8 hours depending on response to
  39. 39. intervention and on patient acuity.  Measure and recordabdominal girth and weight daily.  Prepare patient and assistwith paracentesisif needed. INTERVENTION  Restricted sodium as prescribed  Restrictedfluid intake up to 1000ml/dayas prescribed.  Administered diuretics (tab lasilactone 1 tab OD) as prescribed.  Recorded intake and output strictly.  Measuredand recorded abdominal girth and weight daily. EVALUATION  My goalwas not fulfilled as patient’s edema and ascites was increasedthan before NURSING DIAGNOSIS  Ineffective breathing pattern related to ascites andrestriction of thoracic excursionsecondaryto ascites GOAL Improved respiratory status PLANNING  Elevate head of bed to at least30 degrees  Conserve patient’s strength by providing rest periods and assisting with activities.  Change position every 2 hours.  Administer oxygen as needed INTERVENTIONS  Elevatedhead of bed (semi fowler’s position)  Conservedpatient’s strength by providing restperiods and assisting with activities.
  40. 40.  Changedposition every 2 hours.  Encouragedfor deep breathing and coughing exercise Evaluation My goalwas partially met, as patient reported the improved breathing comfort than before NURSING DIAGNOSIS  Risk for impaired skin integrityrelated to pruritusfrom jaundiceand edema GOAL Decrease potentialfor pressure ulcer development; breaks in skin integrity INTERVENTION  Assessedthe degree of discomfortrelated to pruritus and edema.  Kept the patient’s fingernails short and smooth.  Provided frequent skin care by changing the daily clothes and encouraged to apply powder especially in-between the fingers and toes.  Changedthe patient’s position in every 2 hours  Assessed skinintegrity in every 4–8 hours. Instruct patient and family in this activity.  Restrictedsodium as prescribed.  Encouragedto Perform range of motion exercises every4 hours;  Elevatededematous extremities. EVALUATION My goalwas fully met, as patient did not developed pressure sore and any other skin lesionduring hospitalization NURSING DIAGNOSIS  Highrisk for injury / bleedingrelated to altered clotting mechanisms. GOAL Bleeding tendency will be minimized
  41. 41. PLANNING  Observe for hemorrhagic manifestations:suchas ecchymosis, epistaxis ,petechiae, andbleeding gums.  Observe eachstoolfor color, consistency, and amount.  Be alert for symptoms of anxiety, epigastric fullness, weakness, and restlessness.  Testeachstooland emesis for occult blood.  Recordvital signs at frequent intervals, depending on patient acuity (every 1–4 hours).  Administer vit K as prescribed  Transfuse fresh frozen plasma as prescribed. INTERVENTION  Observedfor hemorrhagic manifestations:such as ecchymosis, epistaxis ,petechiae, andbleeding gums.  Observedeachstoolfor color, consistency, andamount.  Closelyobservedthe symptoms of internal hemorrhage such as anxiety, epigastric fullness, weakness,and restlessness.  Recordedvital signs at frequent intervals,  Administered vit K as prescribed  Transfusedfresh frozen plasma as prescribed. EVALUATION  My goalwas fully met as the patient did not developed the signof haemorrhage during hospitalization.
  42. 42. DAILY PROGRESS NOTEOF PATIENT Date :- 2068/07/13 Admission day  A patient was admitted in male medical ward fromOPD with history of abdominal distention , bilateral pedal edema , mild shortness of breathing and loss of appetite .  On admission patient’s vitals sign were: B.P=110/60 mmof hg, R.R=22/min, Pulse=98/min, Temp.=98ºf weight: 37kg  Patient’s general condition was ill looking.  Mild to moderate shortness of breathing was noticed.  USG abdomen and all base line investigation was ordered MAJOR NURSING INTERVENTION  Admission procedurecarried out  Vein open done and stat medication given  All the ordered investigation send  Monitored vital sing  Maintained intake and output chart  Frequently assessed the patient’s condition  Monitored Weight 1nd day of admission( 2068/07/14)  Patient’s general condition was not improved than yesterday.  Injection vit k added  Doseof tablet lasilactone changed from½ tab to one tab  Fluid restriction <1000ml/day  Low salt diet and egg white BD ordered  Arrangeand transfuse1 pint of FFP B.P=100/60 mmof hg, R.R=22/min, Pulse=96/min, Temp.=98ºf weight: 37kg abdominal girth =31” Intake=1050ml output= 1000ml
  43. 43. MAJOR NURSING INTERVENTION  Assessed in all morning care  Monitored of vital sign regularly  Attended doctor’s round.  Hair comb done  Nail care given  I/V site changed  Daily weight and abdominal girth taken and recorded .  Detail history was done. 2nd day of admission( 2068/07/15)  Patient’s general condition was as same as yesterday.  Serumcreatinine and platelet test order for tomorrow.  Fluid restriction <1000ml/day  Low salt diet and egg white BD ordered  Arrangeand transfuse1 fresh wholeblood. B.P=120/70 mmof hg, R.R=20/min, Pulse=96/min, Temp.=98.8ºf weight: 37.5kg abdominal girth =32” Intake=1050ml output= 9050ml MAJOR NURSING INTERVENTION  Assessed in all morning care  Monitored of vital sign regularly  Attended doctor’s round.  Hair comb done  Daily weight and abdominal girth taken and recorded .  Encouraged for intake of food  Head to toe physicalexamination was done. 3nd day of admission( 2068/07/16)  Patient’s general condition was worsethan yesterday.
  44. 44.  Complain of shortness of breathing and abdominal discomfort.  Serum creatinine and platelet test was send and reportcollected (creatinine =1.7mg/dl, platelet 67,000 mm3)  1pint fresh whole blood was transfused. B.P=140/90 mmof hg, R.R=22/min, Pulse=96/min, Temp.=97ºf weight: 37.5kg abdominal girth =33.2” Intake=800ml output= 700ml Sp02 =92% without o2. MAJOR NURSING INTERVENTION  Assessed in all morning care  Monitored of vital sign regularly  Attended doctor’s round.  Hair comb done  Daily weight and abdominal girth taken and recorded .  Encouraged for intake of food  High fowlers’ position was maintained 4nd day of admission( 2068/07/16)  Patient’s general condition was worsethan yesterday.  Complain of shortness of breathing and abdominal discomfort more severe than yesterday.  Patient was drowsy and lethargic  Nothing was taken fromyesterday evening  Patient party asked for discharge  Patient was discharged on request. B.P=130/90 mmof hg, R.R=22/min, Pulse=100/min, Temp.=99ºf weight: 38kg abdominal girth = 34” Intake=600ml output= 500ml Sp02 =90% without o2. MAJOR NURSING INTERVENTIONS  Assessed in all morning care  Attended doctor round .  Removed the i/v cannula  Performed all dischargeprocedure Provided dischargeteaching on the following topics:
  45. 45.  Medication  Diet  Follow up  Rest and sleep  Regular check up  Prevention of recurrenceof diseaseetc. SPECIAL GAGETS USED IN MY PATIENT  Sphygmomanometer  Stethoscope  ECG monitoring  U.S G machine.  Knee hammer.  Thermometer  Pulse oxymeter. Discharge medication  Tab Lasilactone 1 tab Po OD x 7 days  Tab Pantium 40 mg Po OD x 10 days  Tab Tone 100 PO BD x 7 days  Tab Usoliv 300mg PO BD x 7 days  Inj. Vitamin K 1 amp I/V OD x 3 Days  Fluid restriction < 1000 ml /Day  Low salt diet  Egg white BD Follow up after 1 week and sos. Learned from the Experience ◦ Identified the complete health need of old age . ◦ Provide comprehensive nursing care to the patient having cirrhosis of liver ◦ Provide the opportunity for in-depth study of disease condition ◦ Developcompetencyin handling such disease condition
  46. 46. ◦ Provide the opportunity to o apply the Nursing theory in real situation. ◦ Identified the evaluate the educationalneed of the patient and patient family. SIGNIFICANCE FINDINGSAND SUMMARY chief complain on Admission (2068/07/13)  Abdominal distention since 15-16 days  Bilateralpedal swelling since 10-12 days  Moderate shortness of breathing since 5-7 days  Loss of appetite since 15-16 days On Physicalexaminations Abdominal distention + Fluid thrill + Swelling of face + Hepatomegaly+ Icterus + SignificantInvestigations  SGOT/AST : 187.0 U/L  AGPT/ALT: 88.0 U/L(˂40.0 U/L)  Albumin : 3.4 gm/dl (3.5-5.5 gm/dl)  Bilirubin Total: 2.2mg/dl (0.4-1.0 md/dl)  Prothombin time: 23.3 sec(14-16 sec)  INR : 1.8 ( o.8-1.2)  Creatinine : 2.0 mg /dl  Haemoglobin: 7.8 gm/dl  WBC : 11,600Mm3  Platelets : 61,000Mm3
  47. 47. Liver ultrasound  impression: s/o cirrhosis of Liver, Moderate Ascites MedicalManagement  : fluid restriction  Transfusionof 2 pint FFP  Vit K and inj. polybion supplementary  diuretic drugs (lasilaction)  Daily weight and abdominal girth monitoring Prognosis ofpatient  initially improved than detoriation of condition  Dischargedonrequest on 2068/07/17
  48. 48. PATHOPHYSIOLOGY OF CIRRHOSIS OF LIVER Liver insult, Alcohol ingestion, viral hepatitis, exposure to toxin, Hepatocyte damage Liverinflammation WBC,fever,anorexia, Pain, , nausea,vomitingfatigue, Alterationinbloodandlymphflow Livernecrosis Liverfibrosisand scarring Portal hypertension Acites,Edema,spleenomegaly Anaemia,thrombocytopenia, leukopenia Varices Esophageal varices,superficial abdominal vertices(caputmedusa) Hemorrhoids  Decreasedbilirubin metabolism/biliarytree damage/obstruction  Hyperbilirubinemia  Jaundice  Decreasedbile in gastrointestinal tract  Lightcoloredstool  Increasedurobilinogen  Dark urine  Decreasedvit.K absorption  Bleedingtendency Hormone metabolism Androgen&estrogen  Gynaecomastia  Loss of body hair  Menstrual dysfunction  Spiderangioma  Palmar erythemia ADH & Aldestrone  Edema  Metabolismof protein  Decreased Plasmaprotein  Ascites,edema  Carbohydrate &Fat metabolism  Hypoglycemia  Malnutrition Liverfailure Inabilitytometabolize ammoniatourea Hepaticencephalopathy Hepaticcoma Death Increasedserumammonia,alterationin sleep,asterixis,respiratoryacidosis,foul breath