Liver Cirrhosis

INTRODUCTION
Liver Cirrhosis is derived from Greek word kirrhos, meaning "tawny" (the
orange-yellow colour of the diseased liver). It is a consequence of chronic liver disease
characterized by replacement of liver tissue by fibrous scar tissue as well as regenerative
nodules (lumps that occur as a result of a process in which damaged tissue is
regenerated), leading to progressive loss of liver function. Cirrhosis is most commonly
caused by alcoholism, hepatitis B and C and fatty liver disease but has many other
possible causes. Some cases are idiopathic, i.e., of unknown cause. It is the 11th most
common cause of death in the United States and is most common among people ages 45
– 75. Most cases are a result of alcoholism, but toxins, biliary destruction, hepatitis, and a
number of metabolic conditions may stimulate the destruction process. In the
Philippines, this disease ranks as the 13th leading cause of death and has affected 126, 826
Filipinos in the year 2005. Locally, liver cirrhosis is the 17th leading cause of death.
Gastroenteritis (also known as gastro, gastric flu and stomach flu, although
unrelated to influenza) is inflammation of the gastrointestinal tract, involving both the
stomach and the small intestine resulting in acute diarrhea. The inflammation is caused
most often by infection with certain viruses, less often by bacteria or their toxins,
parasites, or adverse reaction to something in the diet or medication. Worldwide,
inadequate treatment of gastroenteritis kills 5 to 8 million people per year, and is a
leading cause of death among infants and children under 5.
At least 50% of cases of gastroenteritis as foodborne illness are due to norovirus. Another
20% of cases, and the majority of severe cases in children, are due to rotavirus.
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Risk factors include consumption of improperly prepared foods or contaminated water
and travel or residence in areas of poor sanitation. It is also common for river swimmers
to become infected during times of rain as a result of contaminated runoff water. The
incidence is 1 in 1,000 people. It can also be classified as either viral or bacterial. A
major cause of morbidity and mortality in developing nations, gastroenteritis occurs in
people of all ages. In the United States, this disorder ranks second to the common colds
as a cause of lost work time and fifth as the cause of death among young children. It can
also be life-threatening in elderly and debilitated patients. This disorder belongs to one of
the ten causes of morbidity and mortality in the Philippines. Locally, it ranks 14th among
the leading causes of death.
Our patient, given the name “T2”, was chosen as the subject for this case study
because of his condition. He acquired schistosomiasis which led to the removal of his
spleen and then resulted to liver cirrhosis.
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OBJECTIVES
General Objectives:
To conduct a thorough and comprehensive study about the Mr. T2’s disease
according to the data that was gathered by conducting a series of interviews and through
the use of data gathered from extensive research.
Specific Objectives:
• To organize our patient’s data for the establishment of good background
information
• To show the family health history as well as the history of past and present illness
for the knowledge of what could be the predisposing factors that might contribute
to the patient's illness
• To present the family’s genogram containing information that will help out in
tracing any hereditary risk factors
• To trace the psychological development of our patient through analysis of different
developmental theories with comparison to the patient’s data
• To give different definitions of the complete diagnosis of our patient for better
understanding of unfamiliar terms
• To present the data from the physical assessment performed on our patient using
the cephalocaudal approach for a good overview of her over-all health
• To discuss the human anatomy and physiology of the systems involved in the
disease process of our patient
• To identify the symptoms, predisposing and precipitating factors that contribute to
the present illness of the patient
• To organize a flow chart showing the pathophysiology of liver cirrhosis as well as

its relation to acute gastroenteritis for a clear visualization of how this condition
affects a person
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• To list the different orders of the physicians assigned to our patient together with
their rationale for a general knowledge of what consists of the medical
management for liver cirrhosis
• To present the different results of our patient’s diagnostic exams together with
comparisons of normal values for the understanding of what changes during the
disease
• To list the different drugs used by our patient to have a better understanding of its
actions and indications
• To analyze the different nursing theories applicable to our patient
• To formulate specific, measurable, attainable, realistic and time-bounded nursing
care plans
• To impart appropriate health teachings specifically for the patient to promote
wellness
• To present an appropriate discharge plan for our patient

• To have an over-all conclusion and recommendation about the case study
4
PATIENT’S DATA
Patient’s Code name: Mr. T2
Age: 24 years old
Sex: Male
Nationality: Filipino
Religion: Roman Catholic
Civil Status: Single
Occupation: Technician
Ward: Med CP Ward
Hospital No: 1091204
Date of Admission: April 15, 2009
Time of Admission: 12:35 am
Vital Signs on Admission:
BP – 110/ 80mmHg
RR –21 bpm
Temp: 36.7ºC
PR: 76bpm
Mode of Arrival: Stretcher
Admitting Doctor: Dr. Carl Hill N. Florida
Admitting Diagnosis: Liver Cirrhosis: A.G.E. with moderate Dehydration
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FAMILY BACKGROUND
Mr. T2, a 24-year old male, was born in Davao City on September 15, 1984. He is
currently residing at Estores Village, Davao City. They are 7 in the family including his
parents. He is the third child among the five children. Our patient was completely
immunized since he received the needed immunizations before he reached 1 year old.
He enrolled in elementary at B.F. Coucuera Elementary School at Malagamot,
Panacan, Davao City. He finished high school at University of Mindanao at Ilang,
Tibungco, Davao City. Our patient was not able to study in college because of financial
constraints. Our patient used to work in Ateneo College as a technician in the
Engineering Department. At present, he is working at Notre Dame of Marbel as a
technician.
Upon interview, Mr. T2 said that no one in his family had the same disease.
LIFESTYLE
Mr. T2 described his workplace as having a stressful environment as well as his
job. He works six days a week and verbalized that he was always assigned to different
departments and mostly he works more than his hours of duty. He reported that when he
is not working, he usually stays at his boarding house sleeping and eating.
When asked about how he usually spends his days, Mr. T2 was able to formulate
a schedule that would describe his activities of daily living. He would wake up at 6:00
am. The first thing he would do is to take a bath, change to his working clothes then takes
6
his breakfast. He arrives at his workplace at around 7:30 am. It is in there where he does
his work. His duty ends at 5:00 pm but he usually goes home at 9:00 or 10:00 pm because
of overtime. When he arrives at home, he sometimes skips his meals and goes directly to
bed.
DIET
Mr. T2 verbalized that he is fond of eating chicken, egg, hotdog, meat and he
seldom eats vegetables. He admits that he is an occasional drinker but does not smoke.
He said that he only drinks alcoholic beverages whenever there are occasions such as
birthdays and fiestas.
HISTORY OF PATIENT’S PAST ILLNESS
According to Mr. T2, he was hospitalized four times. His first hospitalization was
on 2005 due to melena. He then underwent endoscopy and was diagnosed with ulcer.
When asked about the medicines he took, he immediately said that he cannot recall the
names of those medicines.
His second hospitalization was on 2006 due to schistosomiasis. His chief
complaints were abdominal pain and fatigue and he was not able to determine the real
cause why he acquired such disease. In addition, his diagnostic exam showed that he has
enlarged spleen which needed immediate attention. Due to this, he had undergone
splenectomy on the same year. After the said procedure, he was not able to have follow-
up check-ups.
7
His third hospitalization was on March 15, 2009. His chief complaint was melena
and had an admitting diagnosis of Upper Gastrointestinal Bleeding. During this
hospitalization, he was also diagnosed with Liver Cirrhosis. Among complaints were
yellowish discoloration of skin, insomnia, recurrent fever, fatigue, abdominal pain,
weight loss, nosebleed and nausea.
HISTORY OF PRESENT ILLNESS
Mr. T2’s fourth hospitalization was on April 15, 2009 due to his present illness
which is Acute Gastroenterisits. He verbalized that he experienced diarrhea since
March19, 2009. Three days prior to his admission, he experienced an onset of
undocumented fever associated with diarrhea. Then a day prior to his admission, he had
five episodes of loose bowel movement with blood streaked stools thus prompted the
consult.
EFFECTS OF ILLNESS TO THE FAMILY
During the interview, Mr. T2 was asked regarding the effects of his illness to him
and to his family. He directly said that it greatly affected their family especially on
financial and emotional matters. He said that it is understandable why it affected them
financially because of his hospitalizations. Emotionally they are affected because of the
emotional stress they encounter everytime Mr. T2 is hospitalized.
8
DEVELOPMENTAL DATA
Theorist Theory Stage Result and

Justification
Erik Erikson’s Erik Erikson Intimacy Vs. Isolation The patient has
positively achieved
Psychosocial theorized that (18 to 25 years old)
this stage of
Theory of development is a Individuals feel
development. He
Development lifelong process and established as adults and has the ability to
keep a good
does not end with autonomous from their
relationship with
Source: the cessation of families. A person
other people
Fundamentals adolescence. Just as develops closeness and especially to the
of Nursing,
other sex. He said
3rd Edition physical growth committed meaningful
By: that he is very
Sue C. Delaune patterns can be relationships with other
much happy and
Patricia K.
Ladner predicted, certain people. They see contented with his
current girlfriend
Fundamentals psychosocial tasks themselves as well-
of Nursing, 7th because they were
Edition must be mastered in defined but still feel the
able to establish an
By:
Barbara Kozier, each developmental need to prove themselves intimate
Glenora Erb,
relationship for
Audrey stage. The greater to their parents. They see
Berman, almost 4 years now.
Sherlee Snyder the task this as the time for
He is thankful
achievement, the growing and building time because they both
help each other’s
healthier the for the future.
needs and wants
personality of the A person with a poor
since they both
person. However, sense of self tend to have matured together.
Also, he said that
failure to achieve a less committed
he is one lucky guy
9
task influences the relationships and are more for having a family
who cares for him
person’s ability to likely to suffer emotional
so much and
achieve the next isolation, loneliness, and
supports whatever
task. The resolution depression. his decisions will
be. Without doubt
of the conflicts at A positive outcome in this
T2 did not have any
each stage enables stage is achieved if the
regrets in all his
the person to person establishes an decisions and
things he made
function effectively intimate relationship to
whether it be bad or
in society. another person, accepts
good for as long as
sexual behavior as it’ll serve as a
lesson for him.
desirable, and makes a
commitment to a
T2 said that even
relationship even at times though he is stress
from his workloads,
of stress and sacrifice.
he has his
inspiration and is
still loved by many.
He added that he is
also ready to marry
his current
girlfriend as soon
as he is able.
Lawrence Lawrence Level II: Conventional T2 is a nice and

Kohlberg’s Kohlberg’s theory In this level, the person is considerate person
10
Stages of specifically concerned with according to his
Moral addresses moral maintaining expectations older brother. He
Development development in and rules of the family, prefers to cater to
Source: children and adults. group, nation, or society. the needs of his
Fundamentals The morality of an The person values family before
of Nursing, individual’s conformity, loyalty, and tending to his own.
3rd Edition decision was not active maintenance of Whenever
By: Kohlberg’s concern; social order and control. problems or
Sue C. Delaune rather, he focused Stages: decisions come
Patricia K. on the reasons the Interpersonal along, he puts
Ladner individual makes a Concordance himself to the shoes
decision. His model Orientation: of the others. Thus,
Fundamentals states that a Decisions and behavior understanding the
of Nursing, 7th person’s ability to are based on concerns feelings and
Edition make moral about others’ reaction; the concerns of others
By: judgments and person wants others’ like his family and
Barbara Kozier, behave in a morally approval or a reward. friends. He abides
Glenora Erb, correct manner Law-and-Order and maintains law
Audrey develops over a Orientation: and order by
Berman, period of time. The person wants following the rules,
Sherlee Snyder established rules and the doing one’s duty,
reason for decisions and and respecting
behavior is that social and authority.
sexual rules and traditions
demand the response.
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Robert Havighurst Early Adulthood T2 is not yet
(19 to 29 years)
married but he has
Havighurst’s theorized that there
This stage in a person’s plans on marrying
Developmental are six
his girlfriend as
life is concerned with the
Milestones developmental soon as he can save
achievement of the
enough money.
Theory stages of life, each
following tasks: He was not able to
with essential tasks
achieve the third
 Selecting a
Source: to be achieved. and fourth task
mate since he is still
Fundamentals Mastery of a task in
of Nursing,  Learning to live single with no
3rd Edition one developmental
children to attend
By: with a partner
Sue C. Delaune stage is essential for to. Though he is
Patricia K. X Starting a busy, he still finds
Ladner mastery of tasks in
family time to help his
Fundamentals subsequent stages.
parents in
of Nursing, 7th X Rearing
Edition A successful maintaining the
By: children cleanliness of the
Barbara Kozier, achievement of a
Glenora Erb,  Managing a house. He is
Audrey task leads to
currently working
Berman, home
Sherlee Snyder happiness and to as a technician at
 Getting started Notre Dame of
success with later
in an Marbel in order to
tasks. However,
attend to the wants
occupation
failure leads to and needs of his
 Taking on family. He is also
unhappiness in the
civic aware of his
individual and
responsibilities as a
responsibility
difficulty with later Filipino citizen. For
 Finding a one, he is a
tasks.
registered voter,
congenial
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social group second, pays his
taxes and abides the
laws. He claimed
that he doesn’t find
it hard to interact
with his neighbors
because they are
approachable and
helpful every time
they may have
some problems.
Thus, in return, he
and his family also
render help when
needed. “It’s a give
and take
relationship”, T2
added. He is not a
member of any
social institution,
since he is more
focused with his
job.
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DEFINITION OF COMPLETE DIAGNOSIS
Liver Cirrhosis
A chronic hepatic disease, cirrhosis is characterized by diffuse destruction and
fibrotic regeneration of hepatic cells. As necrotic tissue yields to fibrosis, this disease
alters liver structure and normal vasculature, impairs blood and lymph flow, and
ultimately causes hepatic insufficiency.
Source: Handbook of Medical-Surgical Nursing 3rd Edition by Springhouse
Liver Cirrhosis
Cirrhosis is a consequence of chronic liver disease characterized by replacement
of liver tissue by fibrous scar tissue as well as regenerative nodules (lumps that occur as a
result of a process in which damaged tissue is regenerated) leading to progressive loss of
liver function.
Source: Blackwell’s Dictionary of Nursing 5th Edition
Liver Cirrhosis
Cirrhosis is a chronic, degenerative disease in which normal liver cells are
damaged and are then replaced by scar tissue.
Source: http://www.answers.com/topic/cirrhosis
AGE with Mild Dehydration

A self-limiting disorder, gastroenteritis is an inflammation of the stomach and
small intestine. The bowel reacts to any of the varied causes of gastroenteritis with
hypermotility, producing severe diarrhea and secondary depletion of intracellular fluid. is
the loss of water from the body. With mild dehydration, a related disorder where both
fluids and salts are depleted in the cells or volume depletion.
Source: http://www.answers.com/topic/cirrhosis
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AGE with Mild Dehydration
Gastroenteritis is inflammation of the gastrointestinal tract, involving both the
stomach and the small intestine and resulting in acute diarrhea. With a relative
deficiency of water molecules in relation to other dissolved solutes.
Source: http://en.wikipedia.org/wiki/Gastroenteritis
Gastroenteritis
A self- limiting disorder, gastroenteritis is an inflammation of the stomach and
small intestine.
Source: Handbook of Medical-Surgical Nursing 3rd Edition by Springhouse
Liver Cirrhosis; AGE with mild dehydration

A chronic hepatic disease, cirrhosis is characterized by diffuse destruction and
fibrotic regeneration of hepatic cells. As necrotic tissue yields to fibrosis, this disease
alters liver structure and normal vasculature, impairs blood and lymph flow, and
ultimately causes hepatic insufficiency.
A self-limiting disorder, gastroenteritis is an inflammation of the stomach and
small intestine. The bowel reacts to any of the varied causes of gastroenteritis with
hypermotility, producing severe diarrhea and secondary depletion of intracellular fluid. is
the loss of water from the body. With mild dehydration, a related disorder where both
fluids and salts are depleted in the cells or volume depletion.
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PHYSICAL ASSESSMENT
Patient’s Name: Mr. T2
Age: 24 y.o.
Sex: Male
Ward: Med Cp (DMC)
General Survey:
Our patient, Mr. T2 was assessed on April 17, 2009 at 5:00pm. He was received
lying on bed awake, conscious and coherent. He has an ongoing IVF of D5.3 NaCl 1 liter
regulated @120cc/hr infusing well at L metacarpal vein at 400cc level. He weighs 46
kilograms and he has an ectomorphic body structure. He was responsive and cooperative
when asked.
Vital signs
4:00 pm
BP- 110/60 mmHg
PR- 78 bpm
RR- 24 bpm
Temp.- 37.6 °C
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Skin
Mild jaundice was noted on his skin. He has good skin turgor as skin goes back to
its previous state after being pinched and with a capillary refill of 2 seconds. He has dry
skin with a rough texture. Nails were not properly trimmed and traces of dirt were noted.
Upon palpation, the skin on his forearm is warm.
Head
Our patient’s head is normocephalic. Presence of hair was noted in the head and
in the upper and lower extremities. Lesions, bleeding and bruises were not seen upon
inspection.
Eyes
The sclera is moist and yellowish in color. The iris appears to be black on both
eyes. He has an isocuric pupil reaction of 2mm; round and reactive to light and
accommodation. He verbalized that he can see both near and far objects. Both eyes move
in unison, no signs of scratches and discharges on both eyes noted. Sunken eyeballs are
also noted.
Ears
The shape of the pinnaes are oval and with no discharges noted. Upper margin of
the pinnaes are in line with the outer canthi of the eyes. Ears are firm and non-tender.
Signs of lesions, lacerations, swelling and bruises were not seen upon inspection. He was
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able to repeat a sentence when it was softly said behind his ears, which reveals that he
does not have any hearing problems.
Nose
External surface of the nose is smooth and oily. Nasolabial folds are symmetrical.
Nostrils are also symmetrical with no flaring and discharges noted. Nasal hairs are
present upon inspection. Nasal septum is not deviated. Both nostrils are patent. No signs
of tenderness were noted. Patient was able to distinguish the smell of rubbing alcohol and
female perfume while eyes were closed.
Mouth
Gums and buccal mucosa are pinkish in color. Tongue is in the midline of the
mouth. Tonsils are not inflamed. No signs of inflammation and laceration on the uvula.
Bleeding, ulceration and swelling were not seen upon inspection. Patient was on diet as
tolerated and does not have any difficulty eating and swallowing.
Neck
The neck of our patient can move easily without any difficulty, which includes
right and left lateral, right and left rotation, flexion and hyperextension. Neck can
properly support the head. No signs of enlargement and masses on the thyroid. Carotid
pulse is palpable. No signs of swelling or enlargement of the lymph nodes. No
deformities noted.
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Chest and Lungs
Chest muscle expansion during inspiration and relaxation during expiration are
symmetrical and painless. There were no presence of scars and lesions. He was not in
respiratory distress. Respiratory rate is 24 cycles per minute and rhythm was regular.
Breath sounds were clear on both lungs but upon observing he coughs and whitish
sputum was noted upon coughing.
Abdomen
Patient’s abdomen is flat upon inspection. Palpation was contraindicated due to
his disease. But according to him, he feels a stabbing pain in the hypogastric region on
his abdomen because of presence of dyspepsia. A scar was noted starting in the xyphoid
process until above the mons pubis. Hyperactive bowel movements were noted at 16
sounds in one full minute.
Genito-Urinary
Patient refused to be assessed on his genital area. However, patient verbalized no
pain or difficulty upon urination and defecation. His total urine output for 8 hours was
about 640cc and was able to defecate six times with an output of approximately 1500cc.
Upper extremities
Patient’s upper limbs, shoulders and arms were symmetrical. No tenderness noted
on the bones of the wrist and fingers. No deformities and swelling noted. He could freely
move his shoulders. The patient has a weak grip when he was asked to squeeze one of the
19
student nurse’s hands. No structural deviations noted. T2 was undergoing venoclysis with
IVF of D5.3NaCl 1 liter regulated @120cc/hr infusing well at L metacarpal vein at 400cc
level.
Lower Extremities
Both legs of the patient are symmetrical and can stretch, flex, rotate, extend and
bend without any difficulty. No signs of deformities, lesions, lacerations, bruises and
bleeding were seen upon inspection. Patient has difficulty ambulating because of fatigue,
he needs assistance when he goes to the comfort room.
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ANATOMY AND PHYSIOLOGY
Gastrointestinal Tract
[image from: http://www.lessonsonthelake.com/_images//j0438737.jpg]
The gastrointestinal tract (GIT) consists of a hollow muscular tube starting from
the oral cavity, where food enters the mouth, continuing through the pharynx,
oesophagus, stomach and intestines to the rectum and anus, where food is expelled. There
are various accessory organs that assist the tract by secreting enzymes to help break down
food into its component nutrients. Thus the salivary glands, liver, pancreas and gall
bladder have important functions in the digestive system. Food is propelled along the
length of the GIT by peristaltic movements of the muscular walls.
The primary purpose of the gastrointestinal tract is to break down food into
nutrients, which can be absorbed into the body to provide energy. First food must be
ingested into the mouth to be mechanically processed and moistened. Secondly, digestion
occurs mainly in the stomach and small intestine where proteins, fats and carbohydrates
are chemically broken down into their basic building blocks. Smaller molecules are then
absorbed across the epithelium of the small intestine and subsequently enter the
circulation. The large intestine plays a key role in reabsorbing excess water. Finally,
undigested material and secreted waste products are excreted from the body via
defecation (passing of faeces).
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Cross-section of the small intestine
[image from: http://z.about.com/d/coloncancer/1/0/Y/3/Overview.png]
The digestive tract, from the esophagus to the anus, is characterized by a wall
with four layers, or tunics. Here are the layers, from the inside of the tract to the outside:
• The mucosa is a mucous membrane that lines the inside of the digestive tract from
mouth to anus. Depending upon the section of the digestive tract, it protects the
GI tract wall, secretes substances, and absorbs the end products of digestion. It is
composed of three layers:
o The epithelium is the innermost layer of the mucosa. It is composed of
simple columnar epithelium or stratified squamous epithelium. Also
present are goblet cells that secrete mucus that protects the epithelium
from digestion and endocrine cells that secrete hormones into the blood.
o The lamina propria lies outside the epithelium. It is composed of areolar
connective tissue. Blood vessels and lymphatic vessels present in this
layer provide nutrients to the epithelial layer, distribute hormones
produced in the epithelium, and absorb end products of digestion from the
22
lumen. The lamina propria also contains the mucosa-associated lymphoid
tissue (MALT), nodules of lymphatic tissue bearing lymphocytes and
macrophages that protect the GI tract wall from bacteria and other
pathogens that may be mixed with food.
o The muscularis mucosae, the outer layer of the mucosa, is a thin layer of
smooth muscle responsible for generating local movements. In the
stomach and small intestine, the smooth muscle generates folds that
increase the absorptive surface area of the mucosa.
• The submucosa lies outside the mucosa. It consists of areolar connective tissue
containing blood vessels, lymphatic vessels, and nerve fibers.
• The muscularis (muscularis externa) is a layer of muscle. In the mouth and
pharynx, it consists of skeletal muscle that aids in swallowing. In the rest of the
GI tract, it consists of smooth muscle (three layers in the stomach, two layers in
the small and large intestines) and associated nerve fibers. The smooth muscle is
responsible for movement of food by peristalsis and mechanical digestion by
segmentation. In some regions, the circular layer of smooth muscle enlarges to
form sphincters, circular muscles that control the opening and closing of the
lumen (such as between the stomach and small intestine).
• The serosa is a serous membrane that lines the outside of an organ. The following
serosae are associated with the digestive tract:
o The adventitia is the serous membrane that lines the esophagus.
o The visceral peritoneum is the serous membrane that lines the stomach,
large intestine, and small intestine.
o The mesentery is an extension of the visceral peritoneum that attaches the
small intestine to the rear abdominal wall.
o The mesocolon is an extension of the visceral peritoneum that attaches the
large intestine to the rear of the abdominal wall.
o The parietal peritoneum lines the abdominopelvic cavity (abdominal and
pelvic cavities). The abdominal cavity contains the stomach, small
intestine, large intestine, liver, spleen, and pancreas. The pelvic cavity
contains the urinary bladder, rectum, and internal reproductive organs.
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Motility
The gastrointestinal tract generates motility using smooth muscle subunits linked by gap
junctions. These subunits fire spontaneously in either a tonic or a phasic fashion. Tonic
contractions are those contractions that are maintained from several minutes up to hours
at a time. These occur in the sphincters of the tract, as well as in the anterior stomach.
The other type of contractions, called phasic contractions, consist of brief periods of both
relaxation and contraction, occurring in the posterior stomach and the small intestine, and
are carried out by the muscularis externa.
Stimulation
The stimulation for these contractions likely originates in modified smooth muscle cells
called interstitial cells of Cajal. These cells cause spontaneous cycles of slow wave
potentials that can cause action potentials in smooth muscle cells. They are associated
with the contractile smooth muscle via gap junctions. These slow wave potentials must
reach a threshold level for the action potential to occur, whereupon Ca2+ channels on the
smooth muscle open and an action potential occurs. As the contraction is graded based
upon how much Ca2+ enters the cell, the longer the duration of slow wave, the more
action potentials occur. This in turn results in greater contraction force from the smooth
muscle. Both amplitude and duration of the slow waves can be modified based upon the
presence of neurotransmitters, hormones or other paracrine signaling. The number of
slow wave potentials per minute varies based upon the location in the digestive tract. This
number ranges from 3 waves/min in the stomach to 12 waves/min in the intestines.
Contraction Patterns
The patterns of gastrointestinal contraction as a whole can be divided into two distinct
patterns, peristalsis and segmentation. Occurring between meals, the migrating motor
complex is a series of peristaltic wave’s cycles in distinct phases starting with relaxation
followed by an increasing level of activity to a peak level of peristaltic activity lasting for
5-15 minutes. This cycle repeats ever 1.5-2 hours but is interrupted by food ingestion.
The role of this process is likely to clean excess bacteria and food from the digestive
system.
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Peristalsis
Peristalsis is the second of the three patterns and is one of the patterns that occur during
and shortly after a meal. The contractions occur in wave patterns traveling down short
lengths of the GI tract from one section to the next. The contractions occur directly
behind the bolus of food that is in the system, forcing it toward the anus into the next
relaxed section of smooth muscle. This relaxed section then contracts, generating smooth
forward movement of the bolus at between 2-25 cm per second. This contraction pattern
depends upon hormones, paracrine signals, and the autonomic nervous system for proper
regulation.
Segmentation
The third contraction pattern is segmentation, which also occurs during and shortly after a
meal within short lengths in segmented or random patterns along the intestine. This
process is carried out by longitudinal muscles relaxing while circular muscles contract at
alternating sections thereby mixing the food. This mixing allows food and digestive
enzymes to maintain a uniform composition, as well as to ensure contact with the
epithelium for proper absorption.
Secretion
Every day, seven liters of fluid are secreted by the digestive system. This fluid is
composed of four primary components: ions, digestive enzymes, mucus, and bile. About
half of these fluids are secreted by the salivary glands, pancreas, and liver, which
compose the accessory organs and glands of the digestive system. The rest of the fluid is
secreted by the GI epithelial cells.
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Ions
The largest component of secreted fluids is ions and water, which are first secreted and
then reabsorbed along the tract. The ions secreted primarily consist of H+, K+, Cl-,
HCO3- and Na+. Water follows the movement of these ions. The GI tract accomplishes
this ion pumping using a system of proteins that are capable of active transport,
facilitated diffusion and open channel ion movement. The arrangement of these proteins
on the apical and basolateral sides of the epithelium determines the net movement of ions
and water in the tract.
H+ and Cl- are secreted by the parietal cells into the lumen of the stomach creating acidic
conditions with a low pH of 1. H+ is pumped into the stomach by exchanging it with K+.
This process also requires ATP as a source of energy; however, Cl- then follows the
positive charge in the H+ through an open apical channel protein.
HCO3- secretion occurs to neutralize the acid secretions that make their way into the
duodenum of the small intestine. Most of the HCO3- comes from pancreatic acinar cells
in the form of NaHCO3 in a watery solution. This is the result of the high concentration
of both HCO3- and Na+ present in the duct creating an osmotic gradient to which the
water follows.
Digestive Enzymes
The second vital secretion of the GI tract is that of digestive enzymes that are secreted in
the mouth, stomach and intestines. Some of these enzymes are secreted by accessory
digestive organs, while others are secreted by the epithelial cells of the stomach and
intestine. While some of these enzymes remain embedded in the wall of the GI tract,
others are secreted in an inactive proenzyme form. When these proenzymes reach the
lumen of the tract, a factor specific to a particular proenzyme will activate it. A prime
example of this is pepsin, which is secreted in the stomach by chief cells. Pepsin in its
secreted form is inactive (pepsinogen). However, once it reaches the gastic lumen it
becomes activated into pepsin by the high H+ concentration, becoming a enzyme vital to
digestion. The release of the enzymes is regulated by neural, hormonal, or paracrine
signals. However, in general, parasympathtic stimulation increases secretion of all
digestive enzmes.
26
Mucus
Mucus is released in the stomach and intestine, and serves to lubricate and protect the
inner mucosa of the tract. It is composed of a specific family of glycoproteins termed
mucins and is generally very viscous. Mucus is made by two types of specialized cells
termed mucus cells in the stomach and goblet cells in the intestines. Signals for increased
mucus release include parasympathetic innervations, immune system response and
enteric nervous system messengers.
Bile
Bile is secreted into the duodenum of the small intestine via the common bile duct. It is
produced in liver cells and stored in the gall bladder until release during a meal. Bile is
formed of three elements: bile salts, bilirubin and cholesterol. Bilirubin is a waste product
of the breakdown of hemoglobin. The cholesterol present is secreted with the feces. The
bile salt component is an active non-enzymatic substance that facilitates fat absorption by
helping it to form an emulsion with water due to its amphoteric nature. These salts are
formed in the hepatocytes from bile acids combined with an amino acid. Other
compounds such as the waste products of drug degradation are also present in the bile.
Regulation
The digestive system has a complex system of motility and secretion regulation which is
vital for proper function. This task is accomplished via a system of long reflexes from the
central nervous system (CNS), short reflexes from the enteric nervous system (ENS) and
reflexes from GI peptides working in harmony with each other.
27
ETIOLOGY
Predisposing Factors
Factor Rationale Present or Absent Justification

Extremes of age Extremes of age can Absent Patient is an adult
increase the and does not belong
susceptibility of to the pediatric or
getting ill with AGE geriatric
classification.
Location – The Philippines is Present Patient has lived in
Philippines considered as one of the Philippines for a
the South-East long period of time.
Asian countries that
have high numbers
of E. histolytica.
Race - Filipino The Filipino culture Present Patient is a Filipino,
is fond of eating and has lived in the
without utensils Philippines his
entire life so far.
28
Precipitating Factors
Factor Rationale Present or Absent Justification

Negligence to Failure to do proper Present Patient verbalized
observe proper hand hand washing leads that he does not
washing to increased risk of wash his hands as
ingesting bacteria often as needed.
Facial contact with Facial contact, Present Patient verbalized
surfaces containing especially with the that for a few days,
bacteria. mouth, can lead to he stayed in a ward
increased risk of where he got ill with
ingesting bacteria Acute
Gastroenteritis.
Ingestion poisonous Poisonous plants Absent Patient did not
plants can cause ingest any known
disturbances in the poisonous plant.
GI tract leading to
AGE and other GI
disturbances.
Food allergens Food allergies can Absent Patient does not
also cause GI have any food
disturbances allergies.
Drug reactions from Antibiotic- Absent Patient has not been
antibiotics associated diarrhea examined for AAD.
(AAD)can be Assumption of the
related to AGE presence of this risk
factor cannot be
done.
29
SYMPTOMATOLOGY
Symptom Rationale Present or Absent Justification

Abdominal Pain Pain is felt from the Present Patient verbalized a
gas that accumulates confirmatory remark
in the GI tract. that he indeed
experienced the
symptom.
Nausea and Nausea and Present Patient verbalized a
Vomiting Vomiting is caused confirmatory remark
by the increased that he indeed
motility of the GI experienced the
tract. symptom.
Fatigue Fatigue is caused by Present Patient verbalized a
the rapid losing of confirmatory remark
electrolytes. that he indeed
experienced the
symptom.
Diarrhea Diarrhea is caused Present Patient verbalized a
by the increased confirmatory remark
peristalsis of the that he indeed
intestines. experienced the
symptom.
Dehydration Dehydration is also Present Intake and output
caused by rapid loss documents revealed
of body fluids. that this symptom is
present.
Malaise Malaise is the result Present Patient verbalized a
of the lack of fluids confirmatory remark
in the brain and that he indeed
muscles of the body. experienced the
symptom.
30
Pathophysiology
Precipitating factor:
-Negligence to observe proper

Predisposing factor: hand washing
-Facial contact with surfaces
Extremes of age containing bacteria.
Location – Philippines -Ingestion poisonous plants
Race - Filipino -Food allergens
-Drug reactions from
antibiotics
Ingestion of
bacteria
Endotoxins are
Direct invasion of released
the bowel wall
Stimulation and destruction of

mucosal lining of the bowel wall
Attempted defecation
(tenesmus)
Digestive & absorptive

malfunction
Excessive gas GI
formation distention
ulceration
Flatus
Pain
Nausea &
vomiting
GI bleeding
melena
hematochezia
hematemesis
31
Secretion of Increase peristaltic
F&E in the movement
intestinal lumen
Increase secretion
of Cl & HCO3
Mild diarrhea ions in the bowel
(2-3 stools)
Hyperactive bowel
sound (borborygmi)
F&E imbalance
hypernatremia
Increase protein in
the lumen
Large intestine is
overwhelmed & unable to
reabsorb the lost fluid
Intense diarrhea (>10x)

(watery stool)
Serious fluid volume

deficit
Hypotension Hypovolemic shock
Death
32
Acute gastroenteritis is usually caused by bacteria and protozoan. In the Philippines, one
of the most common causes of acute gastroenteritis is E. histolytica. The pathologic process starts
with ingestion of fecally contaminated food and water. The organism affects the body through
direct invasion and by endotoxin being released by the organism. Through these two processes
the bowel mucosal lining is stimulated and destroyed the eventually lead to attempted defecation
or tenesmus as the body tries to get rid of the foreign organism in the stomach.
The client with acute gastroenteritis may also report excessive gas formation that may
leads to abdominal distention and passing of flatus due to digestive and absorptive malfunction in
the system. Feeling of fullness and the increase motility of the gastrointestinal tract may progress
to nausea and vomiting and increasing frequency of defecation. Abdominal pain and feeling of
fullness maybe relieved only when the patient is able to pass a flatus.
As the destruction of the bowel continues the mucosal lining erodes due to toxin, direct
invasion of the organism and the action of the hydrochloric acid of the stomach. As the protective
coating of the stomach erodes the digestive capabilities of the acid helps in destroying the
stomach lining. Pain or tenderness of the abdomen is then felt by the patient. When the burrows
or ulceration reaches the blood vessels in the stomach bleeding will be induced. Dysentery may
be characterized by melena or hematochezia depending on the site and quantity of bleeding that
may ensue. Signs of bleeding may be observed also through hematemesis.
As the bowel is stimulated by the organism and its toxin, the intestinal tract secretes
water and electrolytes in the intestinal lumen. The body secretes and therefore lost Chloride and
bicarbonate ions in the bowel as the body try to get rid of the organism by increasing peristalsis
and number of defecation. Sodium and water reabsorption in the bowel is inhibited with the lost
of the two electrolytes.
Mild diarrhea is characterized by 2-3 stool, borborygmi (hyperactive bowel sound),fluid
and electrolyte imbalance and hypernatremia. When the condition continue to progress, protein in
the body is excreted to the lumen that further decreases the reabsorption and the body become
overwhelmed that leads to intense diarrhea with more than 10 watery stool. Serious fluid volume
deficit may lead to hypovolemic shock and eventually death.
33
DOCTOR’S ORDER
DATE DOCTOR'S ORDER RATIONALE REMARKS
April 15, Pls. admit under the white The patient is in need of DONE
2009 service at med main level II medical attention so she is
2:45 pm admitted in Davao Medical
Center Hospital
Secure consent for care For legal purposes and to DONE

ensure that the client
understands the nature of the
treatment
TPRq4˚ Vital signs are recorded to DONE

obtain patients baseline data
and are useful for further
management. A temperature
higher than normal may
indicate the development of
infection. Pulse & respiration
is taken to watch out for
tachycardia - a sign of
hemorrhage & dehydration.
Labs: These entire lab tests are DONE
CBC with pc, Blood typing, PT performed to screen for
with INR, Urinalysis, Creatine, alteration and to serve as a
Potassium, Sodium, ECG- 12 baseline data for future
leads, Fecalysis comparison.
Start venoclysis with D5 0.3 Serves as a route for IVTT DONE

NaCl to run for 8 hours fast drip medications and replaces
200 cc now fluid and electrolyte losses
due to frequent loose bowel
movement
Meds: DONE
1. Essentiale forte tab 1 tab Indicated for liver disorders
34
2. Ranitidine 50 mg IVTT now Short term treatment for
every 8 hours gastric ulcer
3. Hyoscine amp 1 amp IVTT Treatment for abdominal

now then every 8 hours pain
4. Metronidazole 500 mg per Treatment for bacterial

amp 1 amp every 8 hours ANST infection
I & O every shift To determine if the patient’s DONE

intake is closely equal to his
output
Refer Referral is done to correct DONE
unusualities as soon as
possible and to inform the
attending physician of the
patient's condition.
April 15, Transfer to blue service, please To render specific treatment DONE
2009 inform service for gastro cases
2:45 pm
April 16, Dx: stool culture To ensure that the needed DONE
2009 specimen will be obtained
6:15 pm for early examination and
diagnosis
For colonoscopy scheduling To aware the NOD and to DONE

schedule for the endoscopic
examination of the colon
Transfer to blue service To render specific treatment DONE
( gastro) for gastro cases
April 16, Dx for CT scan of the whole To test the amount of glucose DONE
2009 abdomen in the blood. An abnormal
10:25 am may signify further
management.
For HBsAg, Anti- HAV To establish a diagnosis of
hepatits B infection and to
assess immune status in
naturally infected and
experimentally vaccinated
individuals
Continue all meds To continue medication
therapy and avoid further
complications
35
patient’s condition
April 16, Admit to CP- Gym (level II) For further specialization of DONE
2009 management
April 17, Still for colonoscopy To follow up previous order DONE

2009 scheduling
(+) BM
7x
3:55 am
Follow up stool culture To ensure that the needed DONE
specimen will be obtained
for early examination
Continue meds. To continue medication DONE

therapy and avoid further
complications
DONE
patient’s condition
36
Diagnostic Exams
Ultrasound Report
Date: March 19, 2009
Result Findings:
The right hepatic lobe is small relative to the left lobe. The liver exhibits a
diffusely coarsened parenchyma with a slightly irregular external outline. No focal mass
lesion seen. There are no dilated intrahepatic ducts.
The gall bladder is normal in size and configuration. The walls are not thickened.
There are no intraluminal echoes nor calculus seen.
There are no abnormal intraluminal masses seen within the common bile duct. It’s
largest antero-posterior diameter is 0.25 cm.
There are no abnormal masses or enlarged lymph nodes in the vicinity of the
abdominal aorta.
The pancreas is normal in size with the following dimensions: head = 1.55 cm,
neck = 0.83 cm, body/tall = 1.35 cm. it exhibits a homogenous parenchymal echopattern
and a regular outline, no focal mass lesions seen.
The spleen is surgically absent.
Length (cm) Width (cm) Thickness (cm) Cortical Thickness (cm)

Right Kidney 11.75 5.87 5.82 1.88
Left Kidney 11.43 5.65 5.50 1.74
There is no significant disparity in the size, shape and location of both kidneys.
They exhibit a isoechoic parenchymal echopattern relative to that of the liver and spleen.
The pelvocalyceal systems as well as the ureters are not dilated no evident mass nor
calculus in one scans obtained.
The urinary bladder is adequately distended showing regular contours and smooth
walls. There are no abnormal intraluminal masses seen within.
The prostate gland measures 3.22 x 3.55 x 2.89 cm (IWT). It exhibits a

homogenous parenchymal echopattern. Approximate weight 17 grams. No calcifications
seen within.
Minimal to moderate amount of fluid collection is present within the abdomen.
37
Impression/Remarks:
• Consider liver cirrhosis correlation with the liver function tests suggested
• Minimal to moderate ascites
• Isoechoic renal parenchymal echopattern, bilateral cannot entirely rule out renal
parenchymal disease based on echogenicity. Serum creatinine correlation
suggested
• Sonographically normal gall bladder, biliary ducts, pancreas, urinary bladder and
prostate glands
• S/P splenectomy
38
IPD HEMATOLOGY
Date: April 02, 2009 @ 09:32
Test Result Flag Limit Reference Range

WBC 15.0 (10E 9/L) H 4.6-10.2 (10E 9/L)
- To determine infection
or inflammation in the
body and monitor its
responses to specific
therapies. Explain to the
patient the necessity of
undergoing the test that
it helps detect
occurrence of anemia
and polycythemia.
LYM 4.8 (RM 32.1 %L) H 0.6-3.4 (10.0-50.0 %L)
- to identify if there is an
abnormal amount of
lymphocyte that may
indicate viral infection
such as HIV. A
decreased number of
lymphocytes in the
peripheral circulation,
occurring as a primary
hematologic disorder or
in association with the
nutritional deficiency,
malignancy or infection
mononucleosis.
MID 1.4 (9.2 %M) 0.0-1.8 (0.1-21.5 %M)
GRAN 8.8 (R4 58.7 %G H 2.0-6.9 (37.0-80.0 %G)
- An elevated level of
granulocytes is
indicative of an
underlying bacterial
infection.
RBC 3.15 (10E 12/L) L 4.69-6.13 (10E 12/L)
- to know the amount of

RBC in the blood. Rule
out anemia due to
nutritional deficiencies,
39
blood loss.
HGB 107 (g/L) L 141.0-181.0 (g/L)
-to identify the amount

of O2 carrying protein
contained within the
RBC.
HCT 28.9 (%) L 43.5-53.7 (%)
- To identify the
percentage of the blood
volume occupied by red
blood cells.
- decreased hematocrit
indicates blood los,
anemia, blood
replacement therapy,
and fluid balance, and
screens red blood cells
status.
MCV 91.7 (fL) 80.0-97.0 (fL)
- Mean corpuscular
volume (MCV) is a
measurement of the
average size of your
RBCs (red blood cells).
The MCV is elevated
when your RBCs are
larger than normal
(macrocytic), for
example in anemia
caused by vitamin B12
deficiency. When the
MCV is decreased, your
RBCs are smaller than
normal (microcytic),
such as is seen in iron
deficiency anemia or
thalassemias.
MCH 34.0 (pg) H 27.0-31.2 (pg)
- Mean corpuscular
hemoglobin (MCH) is a
calculation of the
average amount of
40
oxygen-carrying
hemoglobin inside a red
blood cell. Macrocytic
RBCs are large so tend
to have a higher MCH,
while microcytic red
cells would have a lower
value.
MCHC 370 (g/L) H 318-354 (g/L)
- Mean corpuscular
hemoglobin
concentration (MCHC)
is a calculation of the
average concentration of
hemoglobin inside a red
cell. Decreased MCHC
values (hypochromia)
are seen in conditions
where the hemoglobin is
abnormally diluted
inside the red cells, such
as in iron deficiency
anemia and in
thalassemia. Increased
MCHC values
(hyperchromia) are seen
in conditions where the
hemoglobin is
abnormally concentrated
inside the red cells, such
as in burn patients and
hereditary spherocytosis,
a relatively rare
congenital disorder.
RDW 20.5 (%) H 11.6-14.8 (%)
- Red cell distribution

width (RDW) is a
calculation of the
variation in the size of
your RBCs. In some
anemias, such as
pernicious anemia, the
amount of variation
(anisocytosis) in RBC
41
size (along with
variation in shape –
poikilocytosis) causes an
increase in the RDW.
PLT 262 (10E 9/L) 142.0-424.0 (10E 9/L)
- The platelet count is

the number of platelets
in a given volume of
blood. Both increases
and decreases can point
to abnormal conditions
of excess bleeding or
clotting.
MPV 10.3 (fL) 0.0-99.8 (fL)
- Mean platelet volume

(MPV) is a machine-
calculated measurement
of the average size of
your platelets. New
platelets are larger, and
an increased MPV
occurs when increased
numbers of platelets are
being produced. MPV
gives your doctor
information about
platelet production in
your bone marrow.
42
Clinical Chemistry
Patient name: Rambo Physician: Dr. Otero
Sex:M Age: 24 yrs old Analyzer: VITROS 250
Test initial date: April 02, 2009 Fluid: SERUM
Report print date: 04/02/09 Priority: Routine
TEST RESULT UNIT NORMAL RANGE
ALT H 157 U/L 21 - 72
the most sensitive
indicators of liver cell
irritation or damage. The
activity of this enzyme is
measured in blood plasma.
Elevated levels of this
enzyme can be an
indication of viral hepatitis
and other forms of liver
disease.
ALP H 225 U/L 38 - 126
Alkaline phosphatase are a

family of enzymes that are
present throughout the
body. Elevated levels of
ALP are associated with
liver and bile duct
disorders, and bone
diseases.
TOTAL PROTEIN 81 g/L 63 - 82
Measurement of the total

protein concentration in
plasma. Elevated
concentrations reflect
dehydration, which might
be attributable to
vomiting, diarrhea,
Addison's disease, diabetic
acidosis, and other
conditions.
ALBUMIN L 21 g/L 35 - 50
43
Albumin is the most
abundant protein found in
blood plasma, representing
40 to 60% of the total
protein. Reduced levels of
albumin may reflect a
variety of conditions,
including primary liver
disease, increased
breakdown of
macromolecules resulting
from tissue damage or
inflammation,
malabsorption syndromes,
malnutrition, and renal
diseases.
GLOBULIN H 60 g/L 23 - 35
Globulins are a diverse

group of proteins in the
blood, and together
represent the second most
common proteins in the
bloodstream. An elevation
in the level of serum
globulin can indicate the
presence of cirrhosis of the
liver.
A/G RATIO L .4 1.5 - 2.5

TOTAL BILIRUBIN H 384.0 umol/L 3.0 – 22.0
Unconcentrated H 31.1 umol/L 0.0 - 19.0
BILIRUBIN
Direct BILIRUBIN H 352.9 umol/L 0.0 - 7.0
DATE: 04/02/09
PROTHROMBIN TIME
Patient: 23.7 seconds
Control: 13.5 seconds
INR: 1.8% Activity: 57.0%
44
Clinical Microscopy
Name: T2 Date: April 15, 2009

Age/ Sex: 24 M Hospital #: 1091204
Requesting Physician: Dr. Florida Specimen: Urine
Findings:
A. Physical Examination: B. Chemical Reaction:

Color: Dark yellow Albumin: negative
Apperance: cloudy Sugar: negative
Reaction: 6.0
Specific Gravity: 1.010
C. Microscopic Examination:
Epithelial cells: Cast:

Squamos: + Hyaline: _______/lpf
Renal: ______/ lpf Fine Granular:_____/ lpf
Pus Cells: _____/ hpf Coarse granular:____/ lpf
Musous Threads Crystal:
Bacteria Uric Acid
Yeast cells Calcium Oxalate
Oil globules Urates
Spermatozoa Triple Phosphate
Amorphous Phosphate
Others
45
Lab no.: 11712
Name: T2 Age: 24 Sex: M Log#: 65592 Index date: .4/15/09

Physician: Walk in Reference #: 59560 Print date: 04/15/09
Test Normal Value Result Units
Hepatitis above 2.0 considered 0.712 (NR) COI

as reactive
Meds:
D5.3 NaCl FD 200 cc now then x8 hour
Essentiale forte 1 tab BID
Ranitidine 50 mg IVTT (NOW) then q 8 hour
Hyoscine amp 1 Amp(now) then q 8 hour
Metronidazole 500 mg q 8 hours
46
Generic Name: Essentiale Forte
Brand Name:
Side Effects/
Suggested Mode of Contra Drug Adverse Nursing
Classifications Dose Actions Indications indications Interactions Reactions Responsibilities
- Cholagogues, -Essentiale 1-2 - increase abdominal
- cirrhosis - Contraindicated Drug-drug. 1. Instruct patient on
Cholelitholytics cap tds. functional pain, nausea, proper use of the drug
in patients
- Hepatic
& Hepatic Essentiale status of the diarrhea and
hypersensitive to
steatosis 2. Urge patient to avoid
Protectors Forte Intiailly 2 liver, allergic
(also in cases drug cigarette smoking because
cap tds. improvemen reaction(skin
of diabetes) -in newborn this may increase gastric
Maintenance: 2 t in the rash).
children acid secretion and worsen
cap once-bd. lipids - Acute and
disease
metabolism chronic -in pregnant
caused by hepatitis women 3. Inform patient to take
accelerated drug once daily
- Necrosis of
synthesis of the liver cells prescription at bedtime for
lipoproteins best results.
- Hepatic
in the liver, 4. Tell the physician what
coma and
activation of medicines you are taking,
precoma
the including those bought
phospholipi - Toxic liver without a prescription and
d-depending damage herbal medicines, before
ferments, (including
you start treatment with
47
increased pregnancy Essentiale.
synthesis of toxicosis)
5. Tell the physician
glycogen in
- before taking any new
the liver,
medication while taking
decreased
this one, to ensure that the
the fatty
combination is safe.
infiltration
of the 6. Do not use the medicine
hepatocytes for other health
conditions.
http://en.wikipedia.org/wiki/Essentiale, http://www.drugs-pro.com/liver-disease/essentiale%20forte.html
48
Generic Name: hyoscine butylbromide
Brand Name: Buscopan
Side Effects/
Classifications Dose Actions Indicatio indications Interactions Reactions Responsibilities
ns
- antispasmodic - 0.4 to 0.8 mg P.O. - used to -Spasms - Drug-drug. 1.Assess vital signs and
Antidepressants,
daily relieve of the Hypersensitivi neurologic,
antihistamines,
Adverse
bladder or stomach, ty disopyramide, cardiovascular, and
reactions
quinidine:
intestinal intestines -Abnormal respiratory status.
additive
CNS:
spasms. or bile muscle anticholinergic 2.Monitor patient for
drowsiness,
effects
-relaxing the duct weakness dizziness, urinary hesitancy or
confusion,
muscle that (gastrointe (myasthenia Antidepressants, retention.
restlessness,
antihistamines,
is found in stinal gravis). fatigue 3.Swallow tablets whole
opioid
the walls of tract), -Abnormally analgesics, with a glass of water.
CV:
sedative-
the stomach, including large or tachycardia, Take at least one hour
hypnotics:
palpitations,
intestines those dilated large additive CNS before antacids or certain
hypotension,
depression
and bile associated intestine transient heart anti-diarrhea drugs.
rate changes
duct with (megacolon). Oral drugs: 4. Do not share this
altered absorption
(gastrointest irritable -Hereditary EENT: medication with others.
of these drugs
blurred vision,
inal tract) bowel blood 3. Inform your doctor or
mydriasis,
Wax-matrix
and the syndrome disorders photophobia, pharmacist if you have
potassium
conjunctivitis
reproductive ) known as tablets: increased previously experienced
49
organs and -Spasms porphyrias. such an allergy. If you
GI mucosal GI:
urinary tract of the -Closed angle feel you have
lesions constipation,
(genitourina reproducti glaucoma. dry mouth experienced an allergic
Drug-herbs.
ry tract) ve or -Buscopan reaction, stop using this
Angel's trumpet, GU: urinary
urinary tablets are not jimsonweed, hesitancy or medicine.
scopolia: retention
systems recommended 4. Tell your doctor or
increased
(genitouri for children anticholinergic Skin: pharmacist what
effects decreased
nary under six medicines you are
sweating, rash
tract), for years of age. Drug-behaviors. already taking, including
Alcohol use:
example those bought without a
increased CNS
period depression prescription and herbal
pain medicines, before you
cramps. start treatment with this
medicine.
5. This medicine should
be used with caution
during pregnancy, and
only if the expected
benefit to the mother is
greater than the possible
risk to the fetus,
particularly in the first
50
trimester. Seek medical
advice from your doctor.
6. It is not known if this
medicine passes into
breast milk. It should be
used with caution in
nursing mothers, and
only if the benefits to the
mother outweigh any
risks to the nursing
infant.
7. This medicine may
cause blurred vision and
so may affect your ability
to drive or operate
machinery safely. If
affected do not drive or
operate machinery.
http://www.medicinenet.com/hyoscine_butylbromide-oral/article.htm, http://medical-dictionary.thefreedictionary.com/hyoscine
51
Generic Name: Metronidazole Side Effects/
Brand Name: Flagyl Dose
Classifications Actions Indications indications Interactions Reactions Responsibilities
Anti-infectives, 1 amp q 8° Disrupts PO, IV: Contraindicated Drug-drug: CNS:
antiprotozoals, DNA and Treatment in: Cimetidine may Seizures, 1. Adiminister on empty
antiulcer agents protein of the Hypersensitivit decrease dizziness, stomach or may
synthesis following y. metabolism of headache. administer with food or
susceptible anaerobic Use cautiously metronidazole. EENT: milk to minimize GI
organisms. infections: in: history in Phenobarbital and Tearing irritation.
Therapeutic Intra- blood rifampin (topical only). 2.Instruct patient to take
effects: abdominal dyscrasias, increases GI: medication exactly as
Bactericidal, infections, History of metabolism and Abdominal directed with evenly
trichomonaci gynecologic seizures or may decrease pain, spaced times between
dal or infections, neurologic effectiveness. anorexia, doses, even if feeling
amebicidal skin and problems and Metronidazole nausea, better.
action. skin severe hepatic increases the diarrhea, dry 3.Advised patient to not
Spectrum: structure impairement. effects of mouth, furry skip doses or double up
Most notable infections phenytoin, tongue, on missed doses.
for avtivity lower lithium, and glossitis, 4.Inform patient that
against respiratory warfarin. unpleasant medication can cause
anaerobic tract Disulfiram-like taste and metallic taste.
bacteria infections, reaction may vomiting. 5.Advise patient that
including: CNS occur with Hemat: frequent mouth rinses,
Bacteroides, infections, alcohol ingestion. Leukopenia good oral hygiene and
clostridium. septicemia, May cause acute Neuro: sugarless gum or candy
In addition is and psychosis and Peripheral may minimize dry mouth.
active endocarditis confusion with neuropathy 6.Inform patient that
against: . disulfiram. medication may52
cause
Trichomonas IV: Increased risk of urine to turn dark.
vaginalis, Perioperativ leucopenia with 7.Advise patient to
Generic Name: Ranitidine Bismuth Citrate
Brand Name: Tritec
53
Side
Suggested Mode of Contra Drug Effects/ Nursing
Classificatio Dose Actions Indicatio indications Interactions Adverse Responsibilities
ns ns Reactions
Therapeutic: 50 mg IVTT Inhibits Short Contraindica Drug-drug: CNS: 1. Assess for
Antiulcer now q 8° the action term ted in: Cimetidine confusion, epigastric or
agents of treatment Hypersensiti inhibits drug dizziness, abdominal
histamine of active vity. Cross metabolizing drowsiness, pain and
Pharmacologi at the H2- duodenal sensitivity enzymes in hallucinatio frank or
c: Histamine receptor ulcers may occur. the liver; may ns, occult blood
H2 antagonist site and Some lead to headache. in the stool,
located benign products increase levels CV: emesis or
primarily gastric contained and toxicity in arrythmias gastric
in gastric ulcers. alcohol and the following- GI: Altered aspirate.
parietal Prophyla should be some taste, black 2. Administer
cells, xis of avoided in benzodiazepin tongue,con with meals or
resulting duodenal patients with es, beta stipation, immediate
in ulcers (at known blockers, dark afterward
inhibition lower intolerance. caffeine, stools,diarr and at
of gastric doses). Porphyria calcium hea and bedtime to
acid Manage (ranitidine channel drug- prolong
secretion. ment bimuth blockers, induced effect.
In GERD citrate only). carbamazepin hepatitis, 3. Doses
addition,r treatment Some e, chloroquine, nausea. administer
anitidine and products lidocaine, GU: once daily at
bismuth preventio contain metronidazole, Decreased bedtime to
citrate has n of aspartame moricizine,val sperm prolong
some heartburn and should poric acid and count, effect.
antibacteri , acid be avoided warfarin. impotence. 4. Instruct
al action indigesti in patients Hemat: patient to
against H. on and with Agranuloc take
Pylori. sour phenylketon ytosis, medication
Therapeut stomach uria. aplastic as directed
ic effects: (OTC Use anemia, for the full
Healing use). cautiously anemia, course of
and Cimetidi in: Renal neutropem therapy, even
preventio ne, impairement. nia, if feeling
54
n of famotidin thrombocyt better.
ulcers. e, openia. 5. Inform
Decrease ranitidine Misc: patient that
Nursing Theories
Theorist: Faye Glenn Abdella
Theory: 21 Nursing Problems

Abdellah's theory of nursing stated that it was the “determination of the nature and extent
of nursing problem presented by the individual patients or families receiving nursing care”. She
says a nursing problem presented by a client is a condition faced by the client or client's family
that the nurse, through the performance of professional functions, can assist them to meet.
Abdellah's use of term “nursing problems” is more consistent with nursing functions or nursing
goals than with those client-centered problems. The apparent contradiction can be explained by
her desire to move away from the disease-centered orientation. In her attempt to bring nursing
practice into its proper relationship with restorative and preventive measures for meeting total
client needs, her model seems to swing the pendulum to the opposite pole, from the disease
orientation to nursing orientation, while leaving the client somewhere in the middle.
The student nurses are instruments by which certain nursing problems which are faced
by the client and the client's family are addressed and met. Quality professional nursing care
requires the nurses to identify and solve overt and covert nursing problems. This theory
emphasizes a client-centered approach because it is the primary role of the nurse to alleviate the
patient from whatever suffering she is in and help her meet her needs. Her framework is efficient
enough to address and meet the different requirements of the three major aspects of her
“pendulum model” which consists of client-oriented, nursing-centered and disease-centered
approach.
55
Theorist: Lydia Hall
Theory: Core, Care and Cure Theory

Hall's theory emphasizes the importance of individuals as unique, capable of growth and
learning, and requiring a total person approach. Her definition of health can be inferred to a state
of self-awareness with conscious selection of behaviors that are optimal for that individual. Hall
stresses the need to help the person explore the meaning of his or her behavior to identify and
overcome problems through developing self-identity and maturity. The concept of society or
environment is dealt with in relation to the individual. Hall's theory of nursing involves three
interlocking circles, each one of it represents one aspect of nursing. The same aspect represents
intimate bodily care of the patient. The core aspect deals with the innermost feeling and
motivations of the patient and family through the medical aspects of care.
Care is the sole function of nurses, where as core and cure are shared with other
members of the health care team. The major purpose of care is to achieve interpersonal
relationship with the individual. The nurse plans and prepares a series of independent nursing
interventions that can aid from its condition. These interventions are designed to provide good
and conducive atmosphere, administering drugs to the right patient, right drug and right time.
The nurse also provides health teachings to his client who it can be based on medication
management and independent actions such as advising the client to have complete bed rest.
56
Theorist: Ida Jean Orlando
Theory: Nursing Process Theory
Orlando’s theory was developed in the late 1950s from observations she recorded
between a nurse and patient. Despite her efforts she was able to categorize the records as “good”
or “bad” nursing. It then dawned on her that both formulations of “good” and “bad” nursing were
contained in the records. From these observations she formulated the deliberative nursing
process. The role of the nurse is to find out and meet the patient’s immediate needs for help. The
patient’s presenting behavior maybe a plea for help, however, the help needed may not be what it
appears to be. Therefore, nurses need to use their perception, thoughts about the perception or the
feelings engendered from their thoughts to explore with patients the meaning of their behavior.
This process helps the nurse finds out the nature of the distress and what help the patient needs.
Orlando ’s theory remains one of the most effective practice theories available. The use of her
theory keeps the nurses to focus on their patients. The strength of the theory is that it is clear,
concise and easy to use. While providing the overall framework for nursing, the use of her theory
does not exclude nurses from using other theories while caring for the patient.
Student nurse is finding out the problem and meeting the patient’s immediate needs. This
is possible due to the fact that the nurse seeks out the nature of the problems using her perception
based on her cognitive and motor skills thus having a better understanding of how to address the
needs of the patient with the east possible effort alongside with the greatest and maximal result
and efficiency. The theory is presented with fewer complications thus time and energy is
conserved. This provides the nurse to have more time to focus more on her patient and this
serves as an opportunity to furthermore look for underlying complaints and problems.
57
Date / Cues Needs Nursing Diagnosis Objective of Nursing Intervention Evaluation
Time w/ Rationale Care w/ Rationale
April 17, Subjective: C Acute pain Within the 1.) Perform pain assessment Goal Met:
2009 O [abdominal] related remaining 7 each time pain occurs; Note and
“Dugay-dugay na ang G to flatulence hours of our compare previous reports. Patient was
4:00pm sakit sa akoang tiyan.” N secondary to shift, the ®To identify possible factors able to
“Murag naa’y hangin.” I increase in patient will that worsen the pain; to help out experience less
“4.” [pain scale: T gastrointestinal be able to in further pain control. pain, as
0=none;1-3=mild;4- I motility. experience 2.) Monitor vital signs. evidenced by
6=moderate;7- V less pain as ®Usually elevated during verbalization
10=severe] E R: Increased evidenced occurences of pain. of a pain scale
- gastrointestinal by 3.) Instruct patient to report of 1 and
Objective: P motility increases verbalization pain as soon as it occurs. lessened
E the amount of of decreased ®For non-delayed interventions guarding
-occasional guarding R abdominal gas pain [pain to be performed. behavior
behavior toward the C which exerts scale < 4] 4.) Provide non- toward the
abdominal area noted. E pressure on the and less pharmacological pain abdomen.
-mild grimacing noted. P gastrointestinal guarding management such as
T tract walls resulting behavior therapeutic touch
Vital Signs: U in pain. toward the ®To promote cost-free comfort
A abdomen. 5.) Identify ways to
BP- 110/60 mmHg L Source: Marilynn alleviate/minimize pain
E. Doenges, APRN, ®To promote independent self-
PR- 78 bpm P BC, et. al. Nurse’s care
A Pocket Guide, 10th 6.) Note specific time and
RR- 24 bpm T ed. © 2006. F.A. activity when pain occurs.
T Davis Company, ®To administer medications as
TEMP. - 37.6 °C E Philadelphia, prophylaxis appropriately.
R Pennsylvania 7.) Review ways to minimize
N pain regularly
®To maintain and promote
ability to care for self
8.) Obtain laboratory results
58
from laboratory technician
®To determine possible causes
of pain in the abdomen.
9.) Assist in treating AGE
®To treat the underlying cause
of the pain.
10.) Educate watcher(s) on how
they can help alleviate the pain.
®For continuous cost-free pain
management.
11.) Administer analgesics as
ordered.
®Medications that are ordered
for pain will greatly help in
alleviating pain.
12.) Administer oxygen as
ordered.
®Oxygen therapy can help
alleviate pain.
59
Date / Cues Needs Nursing Diagnosis Objective Nursing Intervention Evaluation
Time w/ Rationale of Care w/ Rationale
April 17, Subjective: N Deficient fluid Within our 1.) Assess level of understanding Goal Met:
2009 U volume related to remaining 7 ®Helps out in determining how to
“Gina-uhaw T excessive fluid loss hours span proceed with patient education and Patient was able
4:00pm ko pirminti” R secondary to of care, instruction. to increase oral
“Mga unom I increased peristaltic patient will 2.) Monitor Vital Signs; note strength fluid intake and
ka beses na T movement in the be able to of peripheral pulses. was able to
ko sige ug I gastrointestinal tract perform ®Deficient fluid volume results in show fluid
balik-balik O activities poor perfusion; perfusion can be intake being
sa CR.” N R: Increased and self- assessed by strength of pulse. greater than
“Basa akong A peristaltic movement treatments 3.) Establish 24-hour fluid replacement fluid output.
mga tae.” L in the gastrointestinal for needs and routes to be used
- tract overwhelms the correction ®Prevents peaks/valleys in fluid level
Objective: M large intestine and of deficient 4.) Note client’s preferences regarding
E hinders it from fluid food and fluids that have high fluid
- T absorbing much volume and content
ectomorphic A needed water, show fluid ®Prevents refusal in offered food and
body B causing excessive intake grater drinks
structure O amounts of fluid to be than output. 5.) Keep fluids within arms reach
-imbalanced L lost through the stool ®Promotes independent self-care
intake and I 6.) Encourage to increase oral fluid
output C Source: Marilynn E. intake
[output is Doenges, APRN, BC, ®Increases hydration rate
greater than P et. al. Nurse’s Pocket 7.) Provide adequate hygiene to entire
intake] A Guide, 10th ed. © body, especially the eyes and mouth.
T 2006. F.A. Davis ®Prevents damage from dryness
Vital Signs: T Company, 8.) Weigh patient daily
BP- 110/60 E Philadelphia, ® indicates overall fluid and
R Pennsylvania nutritional status
mmHg
N
PR- 78 bpm 9.) Administer intravenous fluids as
ordered.
RR- 24 bpm
60
TEMP. - 37.6 ®Increases hydration rate
10.) Educate watchers on how to
°C
monitor intake and output.
®Promotes continuous care.
11.) Administer medications as
prescribed.
®Proper medication will ensure good
recovery.
12.) Give Oral Rehydration Solution,
if not contraindicated.
®Helps out in replacing lost fluids
61
April 17, Subjective N Imbalanced nutrition: Within our 1.) Determine ability to chew, swallow Goal Met:
2009 U less than body remaining 7 and taste.
“Mga unom T requirements related hours span ®Ensures success in future Patient was able
4:00pm ka beses na R to inability to absorb of care, our interventions to increase oral
ko sige ug I nutrients secondary to patient will 2.) Discuss eating habits, food food intake
balik-balik T increased peristalsis be able to preferences, allergies and dislikes with good over-
sa CR.” I of gastrointestinal maintain or ®To appeal to preference and to all appetite.
“Basa akong O tract develop prevent ingestion of non-preferred
mga tae.” N current food/fluid.
A R: Increased nutritional 3.) Assess weight, body build, strength
Objective L peristalsis of the status by and activity level.
-decreased - gastrointestinal tract increasing ®Provides a baseline data for
level of M hinders the small oral food comparison.
sodium E intestine to absorb intake and 4.) Encourage to have of food and
T much needed showing fluids rich in nutrients like preferred
Vital Signs: A nutrients resulting in increased and non-preferred fruits and
B decreased nutrition. appetite. vegetables.
BP- 110/60 O ®Presents a wide-range of food for
L Source: Marilynn E. variety
mmHg I Doenges, APRN, BC, 5.) Use flavoring agents (e.g., lemon,
C et. al. Nurse’s Pocket herbs, salt)
PR- 78 bpm Guide, 10th ed. © ®Enhances appetite; promotes intake
P 2006. F.A. Davis of food
RR- 24 bpm
A Company, 6.) Limit fiber/bulk food and
TEMP. - 37.6 T Philadelphia, carbonated beverages
T Pennsylvania ®May lead to early satiety
°C E 7.) Encourage to restrict self from
R unpleasant sights or odors
N ®May decrease appetite
8.) Consult dietitian/nutritional advisor
as indicated.
62
®Promotes further wellness and
nutrition
9.) Obtain repeated laboratory results
from laboratory technician
®To determine effectiveness of diet
therapy
10.)Educate watcher(s) to watch out
for factors that induce vomiting and/or
regurgitation of food
®Ensures prevention of future
complications
ordered
®Medications ensure good over-all
recovery
12.) Monitor Intake and Output as
ordered.
® To determine water retention.
63
Date / Cues Needs Nursing Diagnosis Objective of Nursing Intervention Evaluation
Time w/ Rationale Care w/ Rationale
April 17, Subjective H Risk for infection Within our 1.) Stress proper hand washing to all Goal Met:
2009 E related to decreased remaining 7 individuals involved in patient’s care
“Gitanggal A immune system hours span ®Ensures control of the spread of Patient was
4:00pm akoang spleen L efficiency 2° post of care, our bacteria and prevention of able to have a
katong ni- T splenectomy and patient will nosocomial infections clean
aging 2005” H liver cirrhosis. be able to 2.) Monitor care givers and watchers environment,
“Nadiagnose have a ®To ensure patient will remain free good hygienic
ko ug liver P R: Complications decreased from contact with suspected bacteria- practices, and
cirrhosis E with the liver and risk of filled surfaces over-all
katong 2006.” R spleen decrease the infection as 3.) Provide frequent proper general bacteria free
C body’s capability to evidenced by and oral hygiene surfaces.
Objective E maintain an optimal a clean ®Reduces surfaces having
P defense against environment, multiplying bacteria
-status: post T infectious bacteria hygienic 4.) Instruct not to wander around too
splenectomy I practices, much or too far
-Admitting O Source: Marilynn E. and general ®May lead to contact with bacteria-
diagnosis: N Doenges, APRN, BC, asepsis. filled surface
“Liver et. al. Nurse’s Pocket 5.) Explain importance of wearing
cirrhosis…” – Guide, 10th ed. © face mask
-location: 2006. F.A. Davis ®Face masks are effective in
DMC H Company, preventing infection by air-borne
Communicable E Philadelphia, bacteria
Pavillion A Pennsylvania 6.)Provide isolation as indicated
L ®Prevents cross contamination
T 7.) Emphasize necessity of taking
H antibiotics as directed
®Premature discontinuation of
treatment may lead to an infection
8.) Occasionally obtain clean linens
Vital Signs: M for the patient to change into
A ®Linens may serve to be a good
64
BP- 110/60 N place for bacteria to proliferate
A 9.) Advise watchers to change unable
mmHg G person to change clothes
E ®Clothes can be a place for bacteria
PR- 78 bpm M to reside
E 10.)Educate watchers on how to
RR- 24 bpm N identify infections
T ®Ensures immediate care to be
TEMP. - 37.6 gathersd
P 11.) Administer antibiotics as ordered
°C A ®Antibiotics serve as prophylaxis
T 12.) Monitor intake and output as
T ordered
E ® to determine water retention.
R
N
65
April 17, S/O: N Risk for impaired Within our 8 1.) VS checked and recorded. Goal Met:
2009 - with U skin integrity r/t hours span ® to have a baseline data.
jaundice T accumulation of bile of care, our 2.) Check and regulate IVF @ ordered Patient was able
4:00pm noted in R salts in skin patient will rate. to demonstrate
the skin I secondary to Liver be able to: ® to prevent further dehydration. behaviors and
upon T Cirrhosis. Demonstrate 3.) Assess for any changes in skin. techniques that
inspecti I behaviors/ ® to determine the causative factors prevents skin
on. O R: At risk for skin techniques 4. Encourage continuation of regular breakdown
- (+)body N being adversely to prevent exercise. like skin care,
malaise A altered. skin ®: to enhance circulation. proper nutrition
- sunken L breakdown. 5.) Maintain strict skin hygiene. intake, exercise
eyeballs ® to prevent the spread of bacteria and and comply
- dry lips M Source: Marilynn E. prevent infection with
E Doenges, APRN, BC, 6.) Provide adequate clothing/covers. medications.
Vital Signs: T et. al. Nurse’s Pocket ®to prevent vasoconstriction.
BP- 110/60 A Guide, 10th ed. © 7.) Observe for reddened/blanched
B 2006. F.A. Davis areas and institute treatment
mmHg O Company, immediately.
L Philadelphia, ®: Reduces likelihood of progression
PR- 78 bpm I Pennsylvania to skin breakdown.
C 8.) Emphasize importance of adequate
RR- 24 bpm nutritional/fluid intake.
P ®: to maintain general good health and
TEMP. - A skin turgor.
T 9.) Note laboratory results pertinent to
37.6 °C T causative factors.
E ® to determine the needed treatment to
R be given.
N 10.) Assist the client in understanding
and following medical regimen and
preventive care and daily maintenance.
66
®: Enhances commitment to plan,
optimizing outcomes.
ordered.
® to treat any underlying cause
12.) Monitor intake and output as
ordered
® to determine fluid and electrolyte
intake and loses
67
Discharge Plan
MEDICATION
• Instruct the patient and family to follow the home medications as prescribed by the
physician.
R: Treatment regimen is important to have faster recovery.
• Explain each purpose of the medication
R: Knowledge about what medications will make the client become aware of what he is
taking and for the family to participate more in the client’s treatment.
• Instruct client not to take over-the-counter drugs without doctor’s knowledge.
R: Non-prescribed drugs may have an antagonistic effect or synergistic effect in any
drug therapy.
• Explain the side effects or adverse reactions of each medication. Instruct the client and
family to watch out for it and to report it immediately as soon as possible to the
physician.
R: Explaining the side effects will let the client and family identify what harmful effects
to expect and for them to distinguish the adverse reaction to medication for them to report
it to their physician immediately.
• Inculcate to the client to comply all the medications prescribed at the ordered dosage,
route and at the ordered time.
R: Taking the drugs at the ordered dose, route and time limits the chance for toxicity and
ensure its effectiveness.
68
• Advice client to take medications with food if not contraindicated or to take medicine one
hour before meals or one hour after meals.
R: Some medications are irritating to the gastric mucosa.
• Let patient complete the whole course of the drug therapy.
R: This can help the patient alleviate the problem and be able to experience the full
therapeutic effect of the medication.
EXERCISE
• Encourage early ambulation.
R: Walking is good exercise and could promote circulation, hence, proper healing.
• Promote exercise to the client especially ROM.
R: This will promote good physical health.
• Instruct client to avoid strenuous activities for at least a week or a month until fully
recovered.
R: Activities that require great muscle strength should be avoided to prevent injury and
muscle strain.
• Advise patient to have adequate rest and sleep.
R: To gain back the lost strength and be able to return to its normal state thus allow ample
time for healing.
• Practice deep breathing exercise.
R: This will help alleviate any pain or discomfort that patient will encounter
69
TREATMENT
• Explain the need of treatment after discharge and must take it seriously so as to prevent
such complications to the patient
R: To make the client and family aware that the treatment does not only end at hospital but
needs to be continued at home to make the client responsible towards medication.
• Explain to the family the condition of the patient and give them factual information about
the illness.
R: To have better understanding of the patient’s condition and to be able to know what
intervention they should give that could not alter the effect of the therapy.
HYGIENE
• Encourage having proper hygiene like taking a bath, meticulous hand washing, and
brushing of teeth every after meal.
R: Hygiene promotes comfort and cleanliness to the patient. It also increases the sense of
wellness, which is very much needed in the therapeutic process.
• Encourage patient to continue hygienic measures practiced at present such as changing
clothes everyday and changing of underwear as often as necessary, keeping the nails
neatly trimmed, maintaining own supplies/items for personal necessities.
R: Keeping all practiced measures is necessary in consistent maintenance of proper hygiene.
Owning personal accessories for hygiene purposes keep client away from contamination and
infectious diseases.
• Provide a calm, clean, and accepting environment.
70
R: Calm, clean and non threatening environment may lessen the occurrence of possible
infection and would be a good place for healing.
OUTPATIENT ORDER
• Inform the patient that follow-up check-up is important to have continuous monitoring
and care even after attainment of the course medical therapy.
R: Through constant visits as out patient, the physician would still monitor the progress of
the therapeutic intervention availed by the patient.
• Advice the client and the family to carry out follow-up diagnostic examinations
R: This is to evaluate the therapeutic response of the patient to the treatment.
• Instruct the family to report any unusual signs and symptoms experienced by the patient.
R: This will help detect early signs and symptoms of recurrence of the disease.
DIET
• Encourage client to eat a variety of nutritious foods like fruits and vegetables once
instructed by the physician.
R: To maintain and promote a healthy body.
• Instruct client to take vitamins as ordered.
R: To boost the body’s defense mechanism.
• Encourage patient to increase oral fluid intake.
R: This hydrates the body for normal functioning and maintain acid-base balance.
• Advise client not to skip meals and have a regular eating pattern/schedule.
R: Regular interval of meals is the basic principle of a good dietary plan.
71
• Tell patient not to eat foods contraindicated by the physician.
R: To prevent the occurrence of complications.
• Instruct patient to avoid drinking liquors and smoking
R: To also avoid illness to be triggered.
72
Prognosis
Poor Fair Good

Category Justification
(1) (2) (3)
1. Duration It has been one month since

of Illness he has been having diarrhea.
Getting infected and
2. Onset of contracting AGE could have
Illness  been avoided by good
hygiene.
3.
Race and location predispose
Predisposin 
T2 to getting AGE
g Factors
2 out of 5 precipitating factors
4. are present. However, these
Precipitatin factors could have been

g avoided by very simple
Factors hygiene and prevention
methods.
5.
Willingness
to take the
 T2 is very willing to take his
medications
medications. He knows the
or
good effects of the drug and
compliance
intravenous therapy.
to
treatment
regimen
6. T2 was admitted to the
environmen  Communicable Pavilion in
t DMC.
73
The most number of family
members that were present in
7. family the ward was 5. This number

support included every member of his
immediate family except the
father.
4 + 2 + 6 = 12
12/7 = 1.7
Calculatio 4x1 1x2 2x3 =

Ranges:
ns =4 =2 6
1.0 – 1.5 = Poor
1.5 – 2.5 Fair
2.5 – 3.0 = Good
T2 has a FAIR prognosis.
His condition has been with him for about a month before he chose to seek treatment. He
took for granted the worsening of his condition. He could have possibly prevented the
complications brought about by his condition if he had only consulted a health care professional
immediately. Also, simple observance of good hygiene could have been a means to prevent him
from contracting the infection of AGE. On the other hand, upon seeking medical care, his family
support and good compliance of medicines were observed. Through this, our prognosis has come
up to the fair category.
74
Recommendation
To the Student Nurses:
We have also evaluated ourselves and have agreed that we have to heed the
recommendations of our clinical instructor. Patient care is our ultimate goal and continuous
monitoring and application of nursing interventions is compulsory for the patient’s recovery.
Data gathering skills should also be honed for accurate presentation of cases.
To the Patient and his family:
Religious taking of medicine was promoted as well as good general and oral hygiene.
Good family support can boost the morale of the patient and continuous holistic care will
improved his over-all health. He must also accept his condition and be aware of it, so that he
could disciplined himself and follow the necessary interventions given.
To the Ateneo de Davao University – College of Nursing
The group is proud to belong to such a prestigious school. We recommend that the
Ateneo de Davao University’s College of Nursing keep up, or improve their inculcation of
morals and values to their student nurses. Aside from that, continuous teaching and evaluating
our skills will lead us to aim a higher standard of education.
75
To the readers:
The group recommends that you, the reader, broaden your knowledge and continue
reading other sources and not base anything on this case presentation alone. A variety of sources
make a good over-all understanding of a subject.
Liver Cirrhosis is not always preventable for those at risk, however, steps can be taken to
lower the chance to develop and to delay the possible outcome. That’s why we recommend that
everybody must take care of themselves in preparing or eating foods. They must also establish
new patterns of eating, drinking, and lifestyle in order to prevent diseases from occurring.
76

Liver Cirrhosis

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Liver Cirrhosis

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INTRODUCTION

orange-yellow colour of the diseased liver). It is a consequence of chronic liver disease

characterized by replacement of liver tissue by fibrous scar tissue as well as regenerative

nodules (lumps that occur as a result of a process in which damaged tissue is

regenerated), leading to progressive loss of liver function. Cirrhosis is most commonly

number of metabolic conditions may stimulate the destruction process. In the

unrelated to influenza) is inflammation of the gastrointestinal tract, involving both the

parasites, or adverse reaction to something in the diet or medication. Worldwide,

inadequate treatment of gastroenteritis kills 5 to 8 million people per year, and is a

leading cause of death among infants and children under 5.

incidence is 1 in 1,000 people. It can also be classified as either viral or bacterial. A

major cause of morbidity and mortality in developing nations, gastroenteritis occurs in

the leading causes of death.

spleen and then resulted to liver cirrhosis.

disease process of our patient

• To identify the symptoms, predisposing and precipitating factors that contribute to

the present illness of the patient

• To organize a flow chart showing the pathophysiology of liver cirrhosis as well as

• To impart appropriate health teachings specifically for the patient to promote

• To present an appropriate discharge plan for our patient

Patient’s Code name: Mr. T2

Age: 24 years old

Religion: Roman Catholic

Civil Status: Single

Ward: Med CP Ward

Hospital No: 1091204

Date of Admission: April 15, 2009

Time of Admission: 12:35 am

Vital Signs on Admission:

Mode of Arrival: Stretcher

Admitting Doctor: Dr. Carl Hill N. Florida

Admitting Diagnosis: Liver Cirrhosis: A.G.E. with moderate Dehydration

He enrolled in elementary at B.F. Coucuera Elementary School at Malagamot,

Panacan, Davao City. He finished high school at University of Mindanao at Ilang,

constraints. Our patient used to work in Ateneo College as a technician in the

Engineering Department. At present, he is working at Notre Dame of Marbel as a

Mr. T2 described his workplace as having a stressful environment as well as his

birthdays and fiestas.

HISTORY OF PATIENT’S PAST ILLNESS

names of those medicines.

His second hospitalization was on 2006 due to schistosomiasis. His chief

and had an admitting diagnosis of Upper Gastrointestinal Bleeding. During this

yellowish discoloration of skin, insomnia, recurrent fever, fatigue, abdominal pain,

weight loss, nosebleed and nausea.

HISTORY OF PRESENT ILLNESS

which is Acute Gastroenterisits. He verbalized that he experienced diarrhea since

March19, 2009. Three days prior to his admission, he experienced an onset of

EFFECTS OF ILLNESS TO THE FAMILY

emotional stress they encounter everytime Mr. T2 is hospitalized.

Theorist Theory Stage Result and

Lawrence Lawrence Level II: Conventional T2 is a nice and

Source: Handbook of Medical-Surgical Nursing 3rd Edition by Springhouse

Source: Blackwell’s Dictionary of Nursing 5th Edition

AGE with Mild Dehydration

Source: Handbook of Medical-Surgical Nursing 3rd Edition by Springhouse

Liver Cirrhosis; AGE with mild dehydration

Patient’s Name: Mr. T2

Ward: Med Cp (DMC)

regulated @120cc/hr infusing well at L metacarpal vein at 400cc level. He weighs 46

BP- 110/60 mmHg

Upon palpation, the skin on his forearm is warm.

does not have any hearing problems.

female perfume while eyes were closed.

pulse is palpable. No signs of swelling or enlargement of the lymph nodes. No