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Objectives of Case study

To gain in-depth knowledge about the study subject/disease


condition.
To gain the conf idence in handling such cases in f uture.
To f ulf ill the partial course objective of M.N. curriculum.
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-graphical Data:

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
Final Diagnosis :- Cirrhosis of Liver
Attending physician :-
Informants Obtained From :- Patient (self) & his son
B : Chief complain

Abdominal distention 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. Present Illness/ Health Status

1. Summary of Present illness;

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

symptoms onset character duration Alleviating Aggravating


factors factor
Abdominal 15- moderate _ _ While
distention 16days taking more
fluids and
alcohol
Bilateral 10-12 moderate _ _ _
pedal days
swelling
since
shortness 5-7 Mild to _ Abdominal Resting in
of days moderate distention upright
breathing position
Loss of since moderate _ _ _
appetite 15-16
days

D.Past Illness:

Childhood Illness Adult Illness


Diseases yes No Disease Yes No
Measles Hypertension
Mumps Heart disease
Whooping Tuberculosis
cough
Polio Diabetes
Rheumatic Filariasis
Fever
Tuberculosis Malaria
Malnutrition Cancer
operation Asthma
Others Accidents
Others

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

2) History of Any of the Disease below in Mother’s and Father’s Family

Disease Father’s Family Mother’s Remarks


Family
yes No yes No
Hypertension
Diabetes
Cancer
Blood disorder
Asthma
Cardiovascular
problems
Arthritis/Gout
Tuberculosis
Other specify

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 .

b) Client’s Coping Pattern:


she is using her past experiences of illness, other life experiences and support from
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 are very kind.
G. Sociological:
a) Family Relationship:
Client’s Position in the Family: she is the eldest person of the family.
Person Living With Client (Support System) : Her Family Members (sons ,daughters
granddaughter and grandsons.
Recent Family Crisis or Changes: according to informant, they have difficult in
managing the time for their sick mother because they have to go for work and
study.
B) Occupational History:
Present Job: she is very old ,so she cannot do any work.
.

c) Educational Level:
Highest Degree or Grade Attended: illiterate
Level of Learning: illiterate)

Cultural:

Ethnic Group: Magar


Client’s Beliefs about Health and Illness: Her beliefs that the illness is caused by
the unhappiness by god.
Client’s Health Practice: According to she , she don’t have 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: she spends her time with her grandsons and grand-
daughters
f) Chemical Use (type, frequency, problems related to use)

Cigarettes: smoker. She takes 3-4 sticks /day


Substances (e.g. Hashish, bidi, etc):- Non –user
Alcohol: she takes alcohol every day about 800-1000ml.

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)

) Kitchen Style: Separate kitchen


e) Types of Fuel Used in Cooking: Fire-Wood

I. Significant Development Task


a) Past if Relevant…………………………………………………………

b)Current in Terms Of Appropriate Task For Age…………..


………………………………………………………………………………….

Developmental tasks of older adulthood

S.N. According to According to patient


book
1 Adjusting to My patient is adjusting her
decreasing health decreasing health and physical
and physical strength as she is depending on
strength 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 My patient has no fixed income so


reduced or fixed she is economically fully depending
income to her family members .
3 Adjusting to death Mrs. Thumisara has already lost her
of spouse husband for 10 years so she is
adjusting to death of spouse
4 Accepting oneself Mrs. Thumisara has full awareness
as an aging person that she is very old and she accepts
oneself as an aging person so she
handed over her kingship to her son
and daughter- in law
5 Maintaining Mrs. Thumisara has not maintained
satisfactory living her own satisfactory living
arrangements arrangement because she is non job
holder women however she is
satisfied whatever she has now.

My patient redefining relationship


6 Redefining with adult children as she is still
relationships with honorable in her family as a head of
adult children. family so she gives her valuable
advice and suggestion to her family
as needed.
7 Finding meaning in My patient is accepting the god’s
life. natural phenomena towards the
living creature and realizing that she
fulfilled her female role sincerely.
Physical Examination
S.N Health History (Subjective Ye No Physical Examination
Data) s (objective Data)
1 General General
Cognation(Limitation/Restricti Gait: Imbalanced
on) Facial Expression (grimacing): undifferentiated
Sensation(Limitation/Restricti Level of consciousness: Conscious
on) Orientation to time ,place and person: fully
Communication(Limitation/Re oriented
striction Measurements
Height: 4feet 6 inch
Weight :37 kg
Temperature : 98°C
Pulse: 90 b/min
Respiration :20 /min
Blood pressure : 110/60 mm of hg

2 Problem related to Head and Hair :black and grey in colour


face Scalp: dirty, dandruff present, no injury, lumps
Headache and other lesions present
Injury Skull: normal in shape
Puffiness of face Face: uniform movement of side of face , slight
edema ,no masses
Sinuses : No swelling , tenderness and
depression
3 Problem Related to Eye/ Condition of Eyelids: No swelling, redness
Vision ,lesions
Condition of Conjunctiva: pale palpebral
Pain conjunctivas, Condition of cornea: transparent
Swelling Colour of Sclera: yellow sclera
Discharge Pupil Size Symmetry: uniform in size and shape
Excessive tears Reaction to light : reactive to light
Difficulty Seeing at Night Discharge from eyes : slightly white sticky
Any other discharge
problems…………………… Visual Acuity: Sub- Normal
Eye Glasses : Not used

4 Problem Related to Ear: Condition of External Ear:


Pain Normally Located external Ear
Tinnitus Drainage from Ear: No discharge of pus , blood
Vertigo ,slightly wax present
Dizziness Lumps or Lesions: Not found
Others ………………….. Ear Drum:
Hearing Aid: Not used
Rinne Test: AC>BC
Weber Test: AC>BC

5 Problems Related to Nose Location : centrally located


Nasal Deviation : Not found
Injury Bleeding: No
Bleeding /Discharge Patency of the Nostrils: patented
Blockage Any Discharge: Not found
Smell: No problem in smelling
Condition of Nasal mucosa:
Pale in colour
Flaring Nostrils: Not presented.
Inflammation: Not found.
Nasal Polyps: Not found
6 Problems Related to Mouth Lips: Dry
Sore on Lips Oral Cavity: Pale mucous membrane of oral
Sore on Tongue cavity
Gum Bleeding Teeth: Missing all teeth
Missing Teeth/ Dentures Tongue: slightly dry and coated tongue
Change in Taste Vocal cord, Uvula and Tonsils: Not enlarged and
Toothache inflamed.

7 Problems Related to Speech Speech Disorders: Not presented.


Loss of Consciousness
Loss of Memory
Convulsion
8 Throat and Neck Location : centrally located, no tilting of head
Difficulty n Swallowing Movement : Full and smooth range of
Problems in Tonsil movement, no stiffness or tenderness
Neck Rigidity Jugular Vein : Not enlarged
Condition of Thyroid: No enlargement of
thyroid gland

Problem Related to Respiratory Rat:20 b/min


Respiration : Depth of respiration: Normal depth
Dyspnoea Quality of Respiration : dyspnoea in lying
Cough position
Hoarseness of Voice Chest Inspection
Cyanosis - lateral diameter is wider than anterior
Others……………………………….. posterior diameter
- sternum is located at the midline
- Even expansion of the chest during
breathing
No intercostals retraction
• Slight cough , but no productive
sputum.

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

10 Heart and Circulation :


Chest pain Pulse Rate: Radical: 88b/min Apical: 88
Numbness b/min
Palpitation Character of Pulse: Normal
Fever , chills Blood Pressure: Right110/60mm of hg
Bleeding tendencies Left: 100/60 mm of hg
Others
:…………………………………………… 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

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

14 Comfort ,Sleep and Rest:


Location Of Pain : Rt. Hypochondrium
Pain tenderness
Regular Sleep Pattern
Discomfort due to abdominal distention
Sleep disturb at night
15 Integumentary Hygiene :
Non –healing sores Colour of skin, Texture, Turgor : Normal
Change in Mole Colour Pigmentation, Lesion, Tumors: Not found
Nail Changes Skin Inflammation : Not present
Itching Of Skin Sensation Edema: present (lower legs and abdomen)
Regular bathing Habit Rashes : Not present
Abnormal Nail 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
16 Reflexes
Biceps Reflex: present
Brachilo radialis: present
Triceps Reflex: present
Patellar Reflex : present
Achilles Reflex: present
Babinski Reflex : present( negative)
Kerning’s sign : Absent

UNIT II - INTRODUCTION TO DISEASE

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.

• Derived from Greek word Kirrhos means Yellowish – brown color.

Definition:

• Cirrhosis is a chronic progressive disease of the liver characterized by


extensive degeneration and destruction of the liver parenchymal cells.
• Cirrhosis is a chronic disease characterized by replacement of normal liver
tissue with diffuse fibrosis that disrupts the structure and function of the
liver.

• The liver cells attempt to regenerate, but the regenerative process is


disorganized, resulting in abnormal blood vessels and bile duct
architecture.

• 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.

Scarring also impairs the liver's ability to:

• control infections

• remove bacteria and toxins from the blood

• process nutrients, hormones, and drugs

• make proteins that regulate blood clotting

• produce bile to help absorb fats—including cholesterol—and fat-soluble


vitamins

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.

Chronic hepatitis B and D.

• 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.

Nonalcoholic fatty liver disease (NAFLD).

• This is associated with obesity, diabetes, protein malnutrition, coronary


artery disease, and corticosteroid medications.
• Autoimmune hepatitis. It is caused by the body's immune system attacking
liver cells and causing inflammation, damage, and eventually cirrhosis.

Genetic factors –

About 70 percent of those with autoimmune hepatitis are female.

Diseases that damage or destroy bile ducts.

• 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.

• Cystic fibrosis, alpha-1 antitrypsin deficiency, hemochromatosis, Wilson


disease, galactosemia, and glycogen storage diseases are inherited diseases
that interfere the liver function properly, Cirrhosis can result.

Drugs, toxins, and infections.

• Drug reactions( Acetaminophen, isonazide, methotrexate) prolonged


exposure to toxic chemicals, parasitic infections, and repeated bouts of heart
failure with liver congestion.

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.

If the alcohol abuse continues, widespread scar formation occurs


throughout the liver.

Post necrotic cirrhosis( macro nodular):

• Most common 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 associated with chronic billiary obstruction and


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, alcohol ingestion, 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,
- spleenomegaly(Anemia,

thrombocytopenia, leucopenia)

- Varices (esophageal varices, hemorrhoids.)

↓ billirubin metabolism – hyperbilirubinemia, jaundice

• ↓ bile in gastrointestinal tract – light colored stool


• ↑ urobilinogen – Dark Urine
• ↓ vit K absorption- bleeding tendency
• ↓ metabolism of protein, carbohydrate, fats→ hypoglycemia,
• ↓ plasma protein- ascites and edema

↓androgen and estrogen detoxification(↓ hormone metabolism)- ↑ estrogen


and androgens hormone – Gynecomastia, loss of body hair, menstrual
dysfunction, spider angioma, palmer erythema, testicular atrophy

• ↓ ADH and aldesterone detoxification so ↑ ADH levels - edema


• Biochemical alteration - ↑ AST, ALT levels, ↑ bilirubin, low serum albumin,
prolong prothombin time, elevated alkaline phosphatase.
• Liver failure
• Hepatic encephalopathy
• Hepatic coma
• Death

Clinical manifestations:

Early manifestations –

No symptoms in the early stages of the disease.


GI disturbances are more common , anorexia, dyspepsia, flatulence,
weakness, fatigue, nausea, vomiting, weight loss, 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, spasm of
biliary duct.
Fever, lassitude, weight loss, enlargement of liver and spleen.
Later manifestations:

May be severe and result from liver failure and portal hypertension.

Jaundice, peripheral edema and ascities develop gradually.


Other late symptoms include skin lesion, hematological disorders, endocrine
disturbances, and peripheral neuropathy.
In the advanced stage the liver becomes small and nodular.
Jaundice:
It results from the functional derangement of liver cells and compression of
bile duct by connective tissue overgrowth.
Jaundice occurs as a result of decreased ability to conjugate and excrete
bilirubin.
If obstruction of the biliary tract occurs, obstructive jaundice may also
occur and usually accompanied by pruritus.
Skin lesion:
Spider angioma ( telangiectasia or spidernavi) are small dilated blood
vessels with a bright red center point and spider like branches occurs in
nose, cheeks, upper trunk, neck and shoulders.
Palmer erythema, a red area that blanches with pressure, is located on the
palm of the hand.
Both lesions are due to increase estrogen in 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.
Coagulation problems 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:
In men, Gynecomastia, loss of axillary and pubic hair, testicular atrophy
and impotence with loss of libido due to increased estrogen level.
In younger female, amenorrhea may occur and in older, bleeding may
occur.
↑aldosterone hormone may cause sodium water retention and potassium
loss.
Peripheral neuropathy:
Probably due to dietary deficiency of thiamine, folic acid and cobalamin.

Clinical manifestations:

According to book According to patient


Compensated Hepatomegaly
Jaundice (bilirubin total 2.2 mg /dl)
• Intermittent mild fever Moderate Ascites
• Vascular spiders Bilateral pedal edema
• Palmar erythema (reddened Losses of appetite
palms)
Abdominal pain
• Unexplained epistaxis
• Ankle edema dull and heavy feeling in right upper
quadrant
• Vague morning indigestion
• Flatulent dyspepsia weakness, fatigue, nausea, weight
• Abdominal pain loss
• Firm, enlarged liver Anemia (pale mucosa ,)
• Splenomegaly Mild shortness of breathing

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

Diagnosis according to book

• Liver function test : ↑alkaline phosphate, ALT,AST and y – glutamyl


transpeptidase ( GGT)
• Blood test: ↓ total protein, ↓ albumin, ↑ serum bilirubin and glubomin
• Prothombin time is prolong
• Liver cell biopsy to identify liver cell changes
• Ascites fluid test
• Liver ultrasound
• CT Scan
• Stool for occult blood

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 most cases there is at least a slight elevation in the serum ALP
and serum aminotransferases. In decompensated cirrhosis all
biochemistry is deranged.

■ Serum electrolytes. A low sodium indicates severe liver disease due to a


defect in free water clearance or to excess diuretic therapy.

■ Serum creatinine. An elevated concentration 130 mol/ L is a marker of


worse prognosis.In addition, serum -fetoprotein if 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


• Liver function test : Liver function test :
↑alkaline phosphate, SGOT/ AST : 187 U/L
ALT,AST and y – SGPT/ ALT: 88.0 U/L
glutamyl transpeptidase ( Alkaline Phosphate: 124 IU/L
Total protein : 6.4 gm/dl
GGT)
Albumin : 3.4 gm/dl
• Blood test: ↓ total protein,
Prothombin time: 23.3 sec
↓ albumin, ↑ serum INR : 1.8
bilirubin and glubomin Bilirubin Total: 2.2mg/dl
• Prothombin time is Creatinine : 2.0 mg /dl
prolong Haemoglobin: 7.8 gm/dl
• Liver cell biopsy to WBC : 11,600 Mm3
identify liver cell changes Platelets : 61,000 Mm3
• Ascites fluid test USG: findings s/o cirrhosis of
• Liver ultrasound Liver, Moderate Ascites
• CT Scan

Others Investigations of patient

Date of According to my patient Normal range


investigation
2068/07/13 Hematology
Hb :7.8gm /dl HB% M-13-15 F-12-14
WBC:11,600 mm3 gm/dl
Platelets :61,000 mm3 WBC-400O-1100mm3
Prothombin Time (test): Platelets 1,50,000-
23.3sec 4,00,000
Prothombin Time (control): Prothombin Time (test)
14.0 sec 14-16 sec
INR : 1.8
Differential count
Neutrophil- 90% Neutrophil-40-70%
Lymphocyte 10% Lymphocyte-30-35%
Esinophil-00 Esinophil -1-2%
Basophil-00 Basophil-0-1%
Biochemistry- report
Blood sugar (R):129.0 mg/dl Blood sugar (R): 60-180
Creatinine: 2mg/dl mg/dl
Sodium : 142.7mmol/l Creatinine: 0.4-1.4 mg/dl
Potassium :3.45 mmol/l Sodium : 135-150 mmol/L
Potassium : 3.3-5.5
mmol/L
Total Protein : 6.4 gm/dl Total Protein :6-8 gm/dl
Albumin: 3.4 gm/dl Albumin: 3.5-5.5 gm/dl

SGOT/AST : 187.0 U/L SGOT/AST : M ˂37 F ˂31


AGPT/ALT: 88.0 U/L U/L
AGPT/ALT ˂40.0 U/L
Alkaline phosphates: 124.0 Alkaline phosphates : M-
IU /L 64 -306 F: 84-306
Blood grouping:’’B’’ Up to 15 yrs: <644
positive Up to 17 yrs : <483
Bilirubin Total: 2.2 mg/dl Bilirubin Total: 0.4-1.0
Bilirubin Total: 0.8 mg /dl mg/dl
Bilirubin Total: 0.1-0.4
ECG : Normal Sinus
rhythm, non specific T wave
abnormality ECG : Sinus rhythm

Urine RE/ME Urine R/E:Acidic


Colour- light yellow Appearance: Clear
Reaction –Acidic Color: P. yellow
Albumin- Nil WBC:3-5/HPF
Sugar-Nil Epithelial cell: 2-4/HPF
transparency- Clear
Pus Cell-2-4 /HPF
RBCs: Plenty
Epithelial cells- 3-4 /HPF

USG abdomen and pelvis: USG abdomen and


Finding S/O Cirrhosis of pelvis: Normal scan
2068/07/16 Liver
Moderate Ascites
Creatinine: 1.7 mg/dl Creatinine: 0.4-1.4 mg/dl

Platelets :67,000 mm3 Platelets 1,50,000-


4,00,000 mm3

Hb : 10.2 gm /dl
068/07/17 Platelets :92,000 mm3

Management (According To Book)


Medical management

• Monitor for complications: Ascites, bleeding esophageal varices and hepatic


encephalopathy and 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 shown to prolong survival or improve survival rate.
• Researchers are studying various experimental treatments for cirrhosis.
Surgical management

• 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.

Maximize liver function:

• 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.

Treat underlying cause:


if cirrhosis is from heavy alcohol use, the treatment is to completely stop
drinking alcohol.
If cirrhosis is caused by hepatitis C, then the hepatitis C virus is treated
with medicine
Prevent Infection:
by adequate rest, appropriate diet, avoidance of hepatotoxic substances.

Beta-blocker or nitrate

• For portal hypertension. Beta-blockers can lower the pressure in the


varices and reduce the risk of bleeding. Gastrointestinal bleeding requires
an immediate upper endoscopy to look for esophageal varices.

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.

Peripheral edema and Ascites:

• Edema results from decreased colloidal oncotic pressure from impaired


liver synthesis of albumin (hypoalbuminia)
• Ascites is the accumulation of serous fluid in the peritoneal cavity.
• Protein move from the blood vessels via the larger pore of sinusoids into the
lymph space.
• When the lymphatic system is unable to carry off the excess protein and
water, they leak through the liver capsule into the peritoneal cavity.

Hepatic encephalopathy:

• Hepatic encephalopathy is a neuropsychiatric manifestation of liver damage.


• It can occur in 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 crosses the blood
brain barrier and produces neurologic toxic manifestations
• Clinical manifestations include changes in neurological and mental
responsiveness, ranging from sleep disturbances to lethargy to deep coma.
• Grading systems are: early stage (stage 0 and 1) euphoria, depression,
apathy, irritability, memory loss, confusion, drowsiness, insomnia.
• Lactulose , low-protein diet improves symptoms in 75 percent of cases.
• Later stages( stage 2 and 3) include slow and slurred speech , impaired
judgment, hiccup slow and deep respiration, babinski reflex, stage 4 include
disorientation to time , place, person.

Hepatorenal syndrome:

• Hepatorenal syndrome is a serious complication of 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 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

• Hemorrhage will be prevented as evidenced by absence of bleeding, normal


vital sign and urine output of at least 0.5 ml/kg/hour

Interventions :

• Assess patient’s condition


• Monitor for hemorrhage bleeding from gums, melena, hematuria,
hematemasis.
• Assess vital sign for sign of shock
• Monitor urine output
• Protect patient from physical trauma to prevent hemorrhage
• Avoid unnecessary injection and apply gentle pressure after injection.
• Instruct the client to avoid vigorous nose blowing, straining with bowel
movement.
• Provide stool softener to prevent straining with rupture of varices.
• Advice to use soft tooth brush to prevent gum bleeding.

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).

Impaired skin integrity related to pruritus from jaundice and edema

Goal: ‘Decrease potential for pressure ulcer development; breaks in skin


integrity’

Interventions:

• Assess degree of discomfort related to pruritus and edema.


• Note and record degree of jaundice and extent of edema.
• Keep patient’s fingernails short and smooth.
• Provide frequent skin care; avoid use of soaps and alcohol-based lotions.
• Massage every 2 hours with emollients; turn every 2 hours
• Initiate use of alternating-pressure mattress or low air loss bed.
• Recommend avoiding use of harsh detergents.
• Assess skin integrity every 4–8 hours. Instruct patient and family in this
activity.
• Restrict sodium as prescribed.
• Perform range of motion exercises every 4 hours; elevate edematous
extremities whenever possible.

High risk for injury related to altered clotting mechanisms and altered level of
consciousness
Intervention

• Assess level of 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 sharp objects (razors) with safer terms.
• Observe each stool for color, consistency, and amount.
• Be alert for symptoms of anxiety, epigastric fullness, weakness, and
restlessness.
• Test each stool and emesis for occult blood.
• Observe for hemorrhagic manifestations: ecchymosis, epistaxis petechiae,
and bleeding gums.
• Record vital signs at frequent intervals, depending on patient acuity (every
1–4 hours).
• Keep patient quiet and limit activity.

Disturbed body image related to changes in appearance, and role function.

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).

Fluid volume excess related to ascites and edema formation

Goal: Restoration of normal fluid volume


Intervention:

• Restrict sodium and fluid intake if prescribed.


• Administer diuretics, potassium, and protein supplements as prescribed.
• Record intake and output every 1 to 8 hours depending on response to
intervention and on patient acuity.
• Measure and record abdominal girth and weight daily.
• Explain rationale for sodium and fluid restriction.
• Prepare patient and assist with paracentesis

Risk for imbalanced body temperature: hyperthermia related to inflammatory


process of cirrhosis or hepatitis

Goal: Maintenance of normal body temperature, free from infection

• Record temperature regularly (every4 hours).


• Encourage fluid intake.
• Apply cool sponges or icebag for elevated temperature.
• Administer antibiotics as prescribed.
• Avoid exposure to infections.
• Keep patient at rest while temperature is elevated.
• Assess for abdominal pain, tenderness

Ineffective breathing pattern related to ascites and restriction of thoracic


excursion secondary to ascites, abdominal distention, and fluid in the thoracic
cavity.

Goal: Improved respiratory status

Intervention

Elevate head of bed to at least 30 degrees

Conserve patient’s strength by providing rest periods and assisting with


activities.
Change position every 2 hours.

Assist with paracentesis or thoracentesis.


Explain procedure and its purpose to patient.
Have patient void before paracentesis.
Support and maintain position during procedure.
Record both the amount and the character of 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


assist the individual, sick or well , in the performance of those activities
contributing to health or its recovery ( or to peaceful death ) that he would
perform unaided if he had the necessary strength, will or knowledge. And to
do this in such a way as to help him gain independence of such assistance as
soon as possible.

The 14 Basic components of Nursing Care

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 difficulty in breathing especially in supine position due to ascites

2 Eat and 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 level is high (2.0 gm/dl)

4 Sleep and rest

Patient has disturb sleep


She has discomfort due to ascites

5 Select suitable clothes-dress and undress.

Patient has no significant problems 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 clean and well groomed and protect the integument

Patient looks dirty


She has risk for skin breakdown due to edema

8 Move and maintain desirable postures.

Patient has only imitated mobility

9. Avoid dangers in the environment and avoid injuring others.


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 because she has no appropriate
environment for worship according to own faith.

12. Work in such a way that there is a sense of accomplishment.

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 recreational activities like talking to


other patients , and staffs

14. Learn, discover, or satisfy the 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

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

Assessed level of activity tolerance and degree of fatigue, lethargy, and


malaise when performing routine ADLs.
Assisted with activities and hygiene when fatigued.
Encouraged rest when fatigued or when abdominal pain or discomfort
occurs.
Encouraged to take diet high in carbohydrates.
Encouraged to 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 volume excess related to ascites and edema formation

Goal

Restoration of normal fluid volume

PLANNING

Restrict sodium and fluid intake if prescribed.


Administer diuretics, potassium, and protein supplements as prescribed.
Record intake and output every 1 to 8 hours depending on response to
intervention and on patient acuity.
Measure and record abdominal girth and weight daily.
Prepare patient and assist with paracentesis if needed.

INTERVENTION

Restricted sodium as prescribed


Restricted fluid intake up to 1000ml/day as prescribed.
Administered diuretics (tab lasilactone 1 tab OD) as prescribed.
Recorded intake and output strictly.
Measured and recorded abdominal girth and weight daily.

EVALUATION

My goal was not fulfilled as patient’s edema and ascites was increased than
before

NURSING DIAGNOSIS

Ineffective breathing pattern related to ascites and restriction of thoracic


excursion secondary to ascites

GOAL

Improved respiratory status

PLANNING

Elevate head of bed to at least 30 degrees


Conserve patient’s strength by providing rest periods and assisting with
activities.
Change position every 2 hours.
Administer oxygen as needed

INTERVENTIONS

Elevated head of bed (semi fowler’s position)


Conserved patient’s strength by providing rest periods and assisting with
activities.
Changed position every 2 hours.
Encouraged for deep breathing and coughing exercise

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

Decrease potential for pressure ulcer development; breaks in skin integrity

INTERVENTION

Assessed the degree of discomfort related 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.
Changed the patient’s position in every 2 hours
Assessed skin integrity in every 4–8 hours. Instruct patient and family in
this activity.
Restricted sodium as prescribed.
Encouraged to Perform range of motion exercises every 4 hours;
Elevated edematous extremities.

EVALUATION

My goal was fully met, as patient did not developed pressure sore and any other
skin lesion during hospitalization

NURSING DIAGNOSIS

High risk for injury / bleeding related to altered clotting mechanisms.

GOAL

Bleeding tendency will be minimized


PLANNING

Observe for hemorrhagic manifestations:such as ecchymosis, epistaxis


,petechiae, and bleeding gums.

Observe each stool for color, consistency, and amount.


Be alert for symptoms of anxiety, epigastric fullness, weakness, and
restlessness.
Test each stool and emesis for occult blood.
Record vital signs at frequent intervals, depending on patient acuity (every
1–4 hours).
Administer vit K as prescribed
Transfuse fresh frozen plasma as prescribed.

INTERVENTION

Observed for hemorrhagic manifestations: such as ecchymosis, epistaxis


,petechiae, and bleeding gums.

Observed each stool for color, consistency, and amount.


Closely observed the symptoms of internal hemorrhage such as anxiety,
epigastric fullness, weakness, and restlessness.
Recorded vital signs at frequent intervals,
Administered vit K as prescribed
Transfused fresh frozen plasma as prescribed.

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

MAJOR NURSING INTERVENTION

Admission procedure carried 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
Dose of tablet lasilactone changed from ½ tab to one tab
Fluid restriction <1000ml /day
Low salt diet and egg white BD ordered
Arrange and transfuse 1 pint of FFP
B.P=100/60 mm of hg, R.R=22/min,
Pulse=96/min, Temp.=98ºf weight: 37kg abdominal girth = 31”
Intake=1050ml output= 1000ml
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.
Serum creatinine and platelet test order for tomorrow.
Fluid restriction <1000ml /day
Low salt diet and egg white BD ordered
Arrange and transfuse 1 fresh whole blood.
B.P=120/70 mm of 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 physical examination was done.

3nd day of admission( 2068/07/16)


Patient’s general condition was worse than yesterday.
Complain of shortness of breathing and abdominal discomfort .
Serum creatinine and platelet test was send and report collected (creatinine
=1.7mg/dl , platelet 67,000 mm3)
1pint fresh whole blood was transfused.
B.P=140/90 mm of 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 worse than yesterday.
Complain of shortness of breathing and abdominal discomfort more severe
than yesterday.
Patient was drowsy and lethargic
Nothing was taken from yesterday evening
Patient party asked for discharge
Patient was discharged on request.
B.P=130/90 mm of 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 discharge procedure
Provided discharge teaching on the following topics:
Medication
Diet
Follow up
Rest and sleep
Regular check up
Prevention of recurrence of disease etc.

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
◦ Develop competency in handling such disease condition
◦ Provide the opportunity to o apply the Nursing theory in real
situation.
◦ Identified the evaluate the educational need of the patient and
patient family.

SIGNIFICANCE FINDINGS AND SUMMARY

chief complain on Admission (2068/07/13)

Abdominal distention 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

On Physical examinations

Abdominal distention +

Fluid thrill +

Swelling of face +

Hepatomegaly +

Icterus +

Significant Investigations

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 : 11,600 Mm3
Platelets : 61,000 Mm3
Liver ultrasound

impression: s/o cirrhosis of Liver, Moderate Ascites

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

initially improved than detoriation of condition


Discharged on request on 2068/07/17
PATHOPHYSIOLOGY OF CIRRHOSIS OF LIVER

Liver insult, Alcohol ingestion, viral hepatitis, exposure to toxin,

Hepatocyte damage WBC, fever, anorexia,

Liver inflammation Pain, , nausea, vomiting fatigue,

Alteration in blood and lymph flow

Liver fibrosis and


Liver necrosis
scarring
Hormone metabolism Decreased bilirubin
metabolism/biliary tree
Androgen &estrogen
damage/obstruction
Gynaecomastia Portal hypertension
Loss of body Hyperbilirubinemia
hair Jaundice Acites, Edema, spleenomegaly
Menstrual Decreased bile in
gastrointestinal tract Anaemia, thrombocytopenia,
dysfunction
Light colored stool leukopenia
Spider angioma
Palmar Increased urobilinogen Varices
erythemia Dark urine
Decreased vit. K Esophageal varices, superficial
ADH & Aldestrone absorption abdominal vertices (caput medusa)
Bleeding tendency
Edema Hemorrhoids
Metabolism of protein

Decreased Plasma protein


Liver failure Ascites ,edema
Carbohydrate & Fat metabolism

Inability to metabolize ammonia to urea Hypoglycemia


Malnutrition
Hepatic encephalopathy

Increased serum ammonia, alteration in


Hepatic coma sleep, asterixis, respiratory acidosis, foul
breath

Death

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