Professional Documents
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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.
Health History:
A: Bio-graphical Data:
Mrs . Thumisara was absolutely fine before 17monts back. Gradually she
developed the problems of abdominal distension, swelling of lower legs and
mild to moderate shortness of breathing, so her family members took her 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. Investigation of symptom
D.Past Illness:
2) Injuries and Accidents: 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 problem before 17
months.
4) Allergies:-According to my patient she has not known allergies to any food,
Drugs and others
5) Medication Taken at 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 she also
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 use to 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’t know the
drug doses, it’s side effect ,indication and contraindications etc.
Family History
1)
No. of children Age(year) Health Status
Krishna Bahadur 48 years Healthy
Marsagni
Pashupati Marsangi 46 years Healthy
Drupati Marsangi 42 years Healthy
Dol Kumari Marsangi 39 years Healthy
Bharat Marsangi 37 years Healthy
FAMILY TREE
75
years
48 46 42 39 37
yrs yrs yrs yrs yrs
yrsyr
F. Psychological: s
a) Client’s Reaction to illness:
Mrs . Thumisara, has normal reaction to her illness .
c) Educational Level:
Highest Degree or Grade Attended: illiterate
Level of Learning: illiterate)
Cultural:
e) Leisure Time Activities: she spends her time with her grandsons and grand-
daughters
f) Chemical Use (type, frequency, problems related to use)
H. Environmental History:
a) Type of Drainage System: Open
b) Types of Toilet Used: Water seal
c) Sources of drinking Water: Tap water (unboiled water)
Chest Palpation
- No tenderness, lump or depression along
the ribs.
Percussion
- Deep resonant sound heard all over the
lungs.
Auscultation
- Breath sounds are heard in all areas of the
lungs.
- Inspiration longer than expiration
- No , rhonchi, wheezing sound was
presented
11 Nutrition / Hydration:
Body Build: Average
Anorexia Body weight : 37 kg
Nausea/ Vomiting Skin Turgor/ Elasticity : Normal
Unusual thirst or hunger Condition of Buccal mucosa : intact
Diaphoresis
Non Vegetarian
Special Diet
Food Dislikes
Ability to Chew or swallow
Resent change in Weight
12 Elimination and
reproduction: Appearance of Urine : yellowish (concentrated)
Pain in Urination Appearance of Stool: Normal
Change in urine colour Any Enlargement of Liver, spleen: moderately
Urinary Retention enlarged liver found.
Frequency of Urination Any Masses in Abdomen: Not Found
Incontinence of Urine Any tenderness in Above Ares: Tenderness in Rt.
Constipation Hypocardium
Diarrhea Size and shape of abdomen: distended
Passing worms, Mucous abdomen
Shifting dullness: present
Distended abdominal veins : slightly
Fluid thrill: present
Abdominal girth: 33 inch
Enlarges Inguinal and femoral Nodes: Not found
Bowel sounds: Present
Elimination and
Reproduction: Lesion or tumors of Rectal Area: Not found
Appearance of Stool Abnormalities of Genito-Urinary Area: Not
Bleeding from Rectum found
Flatulence Female- Rectocele and Cystocele: not present
Heart Burn Uterine prolapsed : not present
Abdominal Pain Discharge : Not present
Discharge from Genitalia Other………………………
Pain or Swelling of scrotum
Any Unexpected vaginal
bleeding ………………….
Any menstrual Disorder
13 Uterine prolapsed
Knowledge of family planning
method
Family Planning Device Used
Bowel Habits:
Regular/ Irregular
Pap Smear Test Done
Mobility :
Difficulty with Ambulation Motor Strength and Mobility: slight reduced
Muscle cramping or Enlargement and Stiffness of Joints: Not present
Weakness Contractures: slightly Present( knee joint)
Muscle Pain Spinal Deformity: Not Present
Back Pain Range of motion Exercise: Cannot move in full
Joint Pain or Swelling Range Of Motion
Limited Joint Movement CANE: use of stick Crutches : Not used
Ability to Do ADLS Walker : Not used Prosthesis : Not Used
Cirrhosis of liver
Introduction
• The term cirrhosis was first used by Rene Laennec (1781-1826) to describe
the abnormal liver color of individuals with alcohol induced liver disease.
Definition:
• The liver slowly deteriorates and malfunctions due to chronic injury. Scar
tissue replaces healthy liver tissue, partially blocking the flow of blood
through the liver.
• control infections
Incidence:
• It is the twelfth leading cause of death, 27,000 deaths each year and
affects men slightly more than women.
• It is the 10th leading cause of death in the US, with mortality rate of 9.2
deaths per 100,000 populations.
• Of those deaths, 45% were alcohol related. Men are more likely than
women to have alcoholic cirrhosis.
• Worldwide, post necrotic cirrhosis is the most common in women.
Mortality is higher from all types of cirrhosis in men and 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 α 1-antitrypsin deficiency
o Wilson's disease
Cryptogenic (unknown)
Etiology:
Alcohol.
• Heavy alcohol for several years can cause 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, estimated that more than 200 million men and close to 300
million women were obese, obesity is a common cause of chronic liver
disease , 17% of liver cirrhosis is attributable to excess body weight.
Chronic hepatitis C.
Chronic hepatitis C causes inflammation and damage to the liver over time
that can lead to cirrhosis and approximately 20% patient will develop
cirrhosis.
• Hepatitis B and D is virus that infects the liver and can lead to cirrhosis,
but it occurs only in people who already have hepatitis B. approximate
10%- 20% will develop cirrhosis.
Genetic factors –
• Several different diseases (cholangitis) can damage or destroy the ducts that
carry bile from the liver, causing bile to back up in the liver and leading to
cirrhosis.
Inherited diseases.
Types of cirrhosis :
Alcoholic (historically called Laennec’s cirrhosis) cirrhosis:
• Also called micro nodular or portal cirrhosis and usually associated with
alcohol abuse.
• 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.
• Most common worldwide, massive loss of liver cells with irregular patterns
of regenerating cells due to complication of viral, toxic or idiopathic
(autoimmune) hepatitis.
Pathophysiology :
Hepatocyte damage
- ascities, edema,
- spleenomegaly(Anemia,
thrombocytopenia, leucopenia)
Clinical manifestations:
Early manifestations –
May be severe and result from liver failure and portal hypertension.
Clinical manifestations:
Decompensate • Ascites
• Jaundice
• Ascites • Weight loss
• Jaundice
• Weakness
• Muscle wasting
• Weight loss
• Continuous mild fever
• Clubbing of fingers
• Purpura (due to decreased
platelet count)
• Spontaneous bruising
• Epistaxis
• Hypotension
• Sparse body hair
• White nails
• Gonadal atrophy
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 .
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.
Hb : 10.2 gm /dl
068/07/17 Platelets :92,000 mm3
• The only surgery that has been proven to improve the chances of long-term
survival is liver transplantation.
• About 80-90 percent of people who undergo liver transplantation survive.
• The diet should be adequate calories and protein (75- 100 gm/day) unless
hepatic encephalopathy is present, in which case protein is limited.
• Restrict fluid 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 regeneration of liver cells.
• Corticosteroids drugs to improve liver function in post necrotic cirrhosis.
Beta-blocker or nitrate
Complications
Portal hypertension:
• The nodules and scar tissue can compress hepatic veins within the liver.
• This causes the blood pressure within the liver to be high, a condition known
as portal hypertension.
• Portal venous pressure is more than 15mmHg or 20 cm of water.
• Is characterized by ↑venous pressure in the portal circulation,
spleenomegaly, large collateral vein, ascites, systemic hypertension, and
esophageal varices.
• The common area to form collateral channels are in the lower esophagus(
the anastomosis of the left gastric vein and azygos vein), the parietal
peritoneum, rectum.
• High pressures within blood vessels of the liver occur in 60% of people who
have cirrhosis
Esophageal Varices:
• Esophageal Varices are a complex of tortuous veins at the lower end of the
esophageal enlarged and swollen as a result of portal hypertension.
• 10-30% of UGI bleeding due to rupture of varices.
• 80% bleeding due to esophageal Varices.
• 20% due to gastric varices.
Hepatic encephalopathy:
Hepatorenal syndrome:
Nursing management :
Assessment
Assess the client client closely for the presence of early manifestations
such as :
Hepatomegaly
Carefully check the laboratory data.
As the disease progresses , assess the manifestations of
complications of cirrhosis such as ascites, portal hypertension
or hepatic encephalopathy
History taking: past and present health history (alcohol intake, medication,
infection etc) chief complain sign and symptoms of disease
Physical examination
Psychosocial assessment
Nursing Diagnosis
• Ineffective tissue perfusion related to bleeding tendencies and varices that may
hemorrhage
Goal
Interventions :
Activity intolerance related to bed rest, fatigue, lack of energy, and altered
respiratory function secondary to ascites.
Outcomes
The patient will maintain a balance between rest and activity as evidenced
by the absence of fatigue
Interventions:
• Assess level of activity tolerance and degree of fatigue, lethargy, and malaise
when performing routine ADLs.
• Assist with activities and hygiene when fatigued.
• Encourage rest when fatigued or when abdominal pain or discomfort
occurs.
• Assist with selection and pacing of desired activities and exercise.
• Provide diet high in carbohydrates with protein intake consistent with liver
function.
• Administer supplemental vitamins (A, B complex, C, and K).
Interventions:
High risk for injury related to altered clotting mechanisms and altered level of
consciousness
Intervention
Goal: ‘Patient verbalizes feelings consistent with improvement of body image and
self-esteem’
Intervention:
• Assess changes in appearance and the meaning these changes have for
patient and family.
• Encourage patient to verbalize reactions and feelings about these changes.
• Assess patient’s and family’s previous coping strategies.
• Assist patient in identifying short-term goals.
• Encourage and assist patient in decision making about care.
• Identify with patient resources to provide additional support (counselor,
spiritual advisor).
• Assist patient in identifying previous practices that may have been harmful
to self (alcohol and drug abuse).
Intervention
1. Breathe normally.
2. Eat and drink adequately.
3. Eliminate body wastes.
4. Move and maintain desirable postures.
5. Sleep and rest.
6. Select suitable clothes-dress and undress.
7. Maintain body temperature within normal range by adjusting clothing and
modifying environment
8. Keep the body clean and well groomed and 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 way that there is a sense of accomplishment.
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.
ASSESSMENT OF PATIENT ON THE BASIS OF 14 BASIS COMPONENTS
1 Breathe normally.
Patient has no problem related to bladder and bowel empty but her serum
creatinine level is high (2.0 gm/dl)
7 Keep the body clean and well groomed and protect the integument
Patient has some problem in this areas because she has no appropriate
environment for worship according to own faith.
NURSING DIAGNOSIS
Activity intolerance related to bed rest, fatigue, lack of energy, and altered
respiratory function secondary to ascites.
GOAL
The patient will maintain a balance between rest and activity as evidenced
by the absence of fatigue
PLANNING
Assess level of activity tolerance and degree of fatigue, lethargy, and malaise
when performing routine ADLs.
Assist with activities and hygiene when fatigued.
Encourage rest when fatigued or when abdominal pain or discomfort
occurs.
Provide diet high in carbohydrates with protein intake consistent with liver
function.
Administer supplemental vitamins (A, B complex, C, and K).
INTERVENTION
Evaluation:
My goal was partially met as patient was complained of less fatigue than before.
NURSING DIAGNOSIS
Goal
PLANNING
INTERVENTION
EVALUATION
My goal was not fulfilled as patient’s edema and ascites was increased than
before
NURSING DIAGNOSIS
GOAL
PLANNING
INTERVENTIONS
Evaluation
My goal was partially met, as patient reported the improved breathing comfort
than before
NURSING DIAGNOSIS
Risk for impaired skin integrity related to pruritus from jaundice and edema
GOAL
INTERVENTION
EVALUATION
My goal was fully met, as patient did not developed pressure sore and any other
skin lesion during hospitalization
NURSING DIAGNOSIS
GOAL
INTERVENTION
EVALUATION
My goal was fully met as the patient did not developed the sign of
haemorrhage during hospitalization.
DAILY PROGRESS NOTE OF PATIENT
Date :- 2068/07/ 13
Admission day
A patient was admitted in male medical ward from OPD 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 mm of 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
Discharge medication
On Physical examinations
Abdominal distention +
Fluid thrill +
Swelling of face +
Hepatomegaly +
Icterus +
Significant Investigations
Medical Management
: fluid restriction
Transfusion of 2 pint FFP
Vit K and inj. polybion supplementary
diuretic drugs (lasilaction)
Daily weight and abdominal girth monitoring
Prognosis of patient
Death