“HEPATIC ABSCESS”

I. GENERAL PROFILE/INFORMATION

a. Name: Mr. MC

b. Age: 52

c. Sex: Male

d. Marital Status: Married

e. Occupation: Farmer

f. Address: Mabaay Bauko, Mountain Province

g. Religion: Roman Catholic

h. Date of Admission: August 03, 2010

i. Admitting physician: Joy R. Fongayao, M.D.

j. Admitting Diagnosis: Right Hepatic Abscess T/C Amebic

II. CHIEF COMPLAINTS

- The patient was admitted at the present hospital due to loose bowel movement, intermittent
fever and pain on the right upper abdominal quadrant characterized as intermittent and dull in
nature since the third week of July.

III. HISTORY OF PRESENT ILLNESS

About 3 weeks prior to admission, the patient experienced pain on the right upper abdominal
quadrant and epigastric area which he rated as 6/10 in a scale of 1-10 (where 1 as the lowest and 10
as the highest) described as dull and occurs intermittently. He also had a loose bowel movement
and appears to occur 6-7 times in a day and associated by an intermittent fever. No consultation
was done. However, significant others had given him antacid and stroke medication (Amlodipine).

On the third week of July 2010, the pain increased in intensity that he cannot tolerate. He was
admitted then to Abatan Louis Nora Hospital for 1 week. However, due to minimal improvements
noted, his wife decided to bring him back home. Medication of Omeprazole 1 tablet for three times
a day was given.

Days later after discharge, the pain he felt persisted. Few hours prior to his admission, his
condition worsened and is already accompanied by fever, nausea and vomiting. The patient was
brought to this institution for further evaluation and subsequently admitted

V. SOCIAL AND ENVIRONMENTAL HISTORY

The patient primarily works as a farmer whiles his wife as a Day Care Teacher. They both have
an ethnic background of Kankana-ey. The patient is a smoker and able to consume 1 pack of
cigarette per day. He used to be a cigarette smoker and an alcohol drinker since teenager. His diet

2
 mostly includes vegetables they harvest in their garden. Occasionally, they also attend some
traditional practices such as wat-wat.
The patient and his family do not have beliefs that could affect their reactions and preferences
with regards of interventions or status.

VI. FAMILY HISTORY

The patient has a family history of hypertension and asthma. His mother died year 2003 due to
stroke that resulted to paralysis of the left side of her body. His father died year 1968 due to peptic
ulcer disease. He has ten siblings and some inherited hypertension and asthma.
Mr. MC has seven children. Among them, the eldest (10 y/o) and the youngest (2y/o) suffer
from asthma.

VII. PHYSICAL EXAMINATION

A.GENERAL SURVEY

Mr. MC., a 52 year old farmer, was admitted to the surgical unit of Baguio General Hospital for
a chief complaint of right upper abdominal quadrant pain and was diagnosed with right hepatic
abscess. At the present time, he complains for pain. When asked to rate his pain in scale of 1-10 (10
being the most severe and 1 as the least), he gave an answer of 7/10 described as a severe dull pain.
The patient then assumes comfort usually in side-lying position and illicit guarding behavior over
abdomen. Grimacing may also be noted at times. He said that the pain usually occur at 3-4 hours
interval.
When received, he has an intravenous infusion of PLRS regulated at 20-21 drops per minute
infusing well on his left hand.
He is conscious and coherent. He has weakness at the right arm and right leg due to a
complication of stroke he had last month of June. He can raise his right extremities to at least an angle
of 10-15degrees however; he’s still non-ambulatory and needs assistance in doing activities of daily
living especially in positioning. He can freely move his left arm and left leg. He sometimes felt body
pains.
He uses bed pan in bowel movement and uses a bottle of dextrose as a urinal.
Other assessment includes his weight of 51 kg and his height is 173 cm. He attested also that he
usually weighs 67 kilograms before when having a c heck –up at a nearest health center.

B.HEENT

The patient’s head is proportionate to body size. Black- colored hair with some noted grey
colored ones are evenly distributed over scalp. Presence of flakes was noted by parting his hair in
several areas. No signs of other infestation such as lice or nits noted. Absence of nodules or masses
was noted upon palpation of the skull. No local deformities from a trauma were noted.
Eyes are symmetrical in level with each other however, with an icteric sclerae. Pupils are
equally round and reactive to light accommodation. The patient attested sensitivity to light
accommodation and feels dizzy each time exposed to it. In regards, his wife utilizes a face towel to
protect his eyes from excessive light accommodation. No noted sunken eyeballs and periorbital edema.
The ear has a proportionate color with the head and face. There are no visible lumps or lesions
seen. Both auricles are firm and not tender upon palpation. No ear discharges noted. By having a
conversation, the patient requests to repeat the statements, leans forward or turns the head toward
the speaker for a clearer hearing. Thus, he has a diminished hearing acuity in both ears due to aging
process.
The nose is symmetrical, no deformities and lesions noted. No nasal discharge or flaring noted.
Air moves freely as the client breathes through the nares. He is able to distinguish unpleasant odors
from the environment.
The neck is symmetrical, no distension and bulging noted. Sometimes, he complains for nape
pain which is due to an increased blood pressure. Color is proportionate to head and face. Lymph
nodes are not palpable. No reported or diagnosed throat problems.

C. RESPIRATORY SYSTEM

The patient has a respiratory rate ranging from 16- 22 cycles per minute. Respiration described

3
as neither too shallow nor too deep. Symmetrical chest wall expansion noted. No presence of any
abnormal breath sounds such as crackles, wheezing and ronchi noted upon auscultation. Respiratory
excursion(use of accessory muscle) noted as 4cm which is in the range of the normal 3-5cm thoracic
expansion. For a better lung expansion, he is placed to semi- fowler’s position.

D. CARDIOVASCULAR SYSTEM

The patient's pulse rate ranges from 60- 75 bpm. His radial pulse was used in monitoring his
pulse rate. Rhythm is normal and regular, no bounding or irregularities noted. His blood pressure taken
ranges from 110/70-140/100 mmHg. When his blood pressure increases to even 140/100 mmHg, the
patient complains for dizziness and pain on the nape area with duration to approximately 3-4 hours.
His heart sounds heard through a stethoscope are loud and distinct.
In his laboratory results, his RBC, Hct and Hgb counts are very low which implies that he’s at
the edge of being anemic.

E. GASTROINTESTINAL SYSTEM

Upon assessment, the patient attested abdominal pain, most especially in the right upper
quadrant. He sometimes complained of nausea and vomiting. His abdomen was flat and not distended.
He has a hyperactive bowel sounds noted as 36-38 per minute which is more than the normal range of
5-34 per minute. He passes- out a loose watery stool about 3-4 times in a day and the same frequency
was during the days of admission. However, he’s stool was described as light yellow and soft in
consistency on the last day of our rotation. As to his fecalysis, a presence of ova and parasites was
noted.
The patient is on diet as tolerated, however, with low fat contents. At times, he complains for
nausea and vomited twice during the first day of our rotation. Vomitus described as with minimal solid
particles. He is able to consume 25-50% of food served. The patient also complained for weight loss
as evidenced by a decrease in his weight from 67 kgs. to 51kgs. When trying to take his Body Mass
Index, it reveals an answer of 17.05 and interpreted as undernourished from the normal range of 20-25.

F. GENITO-URINARY SYSTEM

The patient verbalized no difficulty in urinating. He voids 6-8 times in a day using a dextrose
bottle as a urinal due to activity intolerance. Amount ranges from 220-1350cc per day(800-
2000ml/day). Urine is described as yellow-colored and slightly turbid. There were no signs of glucose
and proteins in the urine as evidenced by his urinalysis. No other urinary problems were diagnosed by
the health team as of the present time.

G. MUSCULO- SKELETAL SYSTEM

As a complication of stroke he had last month of June, the right side of his body was paralyzed
contributing to a decrease in his muscle strength up to the present time. He can raise his right
extremities to an approximate angle of 10-15degrees however, is non-functional. If trying to compare,
his right extremities has a decreased muscle mass due to paralysis.
At times, he complains for body weakness. He lies supine in bed most of the time and needs
assistance in positioning. He is non- ambulatory, thus cannot attend bathroom privileges. He cannot
perform his activities of daily living without any assistance.
Passive exercise and gradual increase of activity as tolerated is encouraged.

H. INTEGUMENTARY SYSTEM

The patient has a normal brown complexion and is proportionate to his entire body. No signs of
edema and dehydration noted. He is able to differentiate cold and warm stimuli. Hair is dry and evenly
distributed over scalp. No presence of infection such as lice noted and with no scalp lesions. He has
pink nail beds with an angle of 160 degrees; no clubbing noted. His capillary refill is 1-2 seconds and
with good skin turgor. Pruritus is not present.
When tried to test his sensation in extremities, his right hand and leg has a diminished sensation
to touch, pain and temperature.
His temperature ranges from 36.7-38.4 degrees Celsius. As it reveals, he had fever once in our

4
rotation for temperature of 38.4 degree celsius. The said problem was accompanied by chills and
diaphoresis. Skin is hot to touch.

5
VIII. DIAGNOSTICS

Date and time the Diagnostic Description of the diagnostic Significance/ Highlight of the significant findings Implications of
diagnostic procedure procedure purpose of the findings
procedure the
conducted procedure
Ultrasound of the abdomen is a non- Detects small The liver is slightly enlarged with smooth Diagnosis:
August 3, 2010 Ultrasound invasive test focuses high frequency abdominal borders and homogenous parenchymal Abscess at the
of abdomen sound waves over an abdominal masses, fluid- echopattern, however a well encapsulated right lobe of the
organ to obtain an image of the filled cysts, solid mass with low levels of floaters liver
structure. gallstones, measuring about 12x13cm is seen on the
Nursing interventions: dilated bile right hepatic lobe. The intrahepatic ducts
>Instruct the patient to avoid eating ducts, ascites, and vessels are undilated
for eight to twelve hours before the and vascular
test. abnormalities Gallbladder is not enlarged, with thin
>Instruct to wear comfortable, loose- . walls.
fitting clothing for the exam. Proximal and distal CBD are unduated.
>Instruct to remove all clothing and
jewelry in the area to be examined. Pancreas and spleen are normal.
>Assist in wearing a gown during the
procedure.
COMPLETE BLOOD COUNT August 3, 2010

Examination Result Reference range Significanc Implications

e
WBC 13.4 x 10^9/L 5.0-10.0 High Due to the presence of infection in the liver, the inflammatory process occurs as
Lymphocytes 2.5 x 10^9/L 0.8-4.0 Normal a response of our body resulting to an increase in WBC and granulocytes.
Midcells 0.7 x 10^9/L 0.1-0.9 Normal
Granulocytes 10.2 x 10^9/l 2.0-7.0 High
Mid% 5.7% 3.0-9.0 Normal
Gran% 75.8% 50.0-70.0 High
Hgb 103g/L 140-180 Low Due to the loss of sodium.
RBC 3.56 x 4.00-5.50 Low The patient is suffered from stroke and is suffering from right sided paralysis

6
 10.12/L which results to the inadequate production and circulation of red blood cells
Hct 31.8% 40.0-54.0 Low from the bone marrow.
MCV 89.6/L 82.0-95.0 Normal The MCV shows the size of the red blood cells.
MCH 28.9pg 27.0-31.0 Normal The MCH value is the amount of hemoglobin in an average red blood cell.
MCHC 323g/L 320-360 Normal The MCHC measures the concentration of hemoglobin in an average red blood
cell.
RDW-CV 14.3 11.5-14.5 Normal Red cell distribution width (RDW) can also be measured which shows if the
RDW-SD 47.3/L 35.0-56.0 Normal cells are all the same or different sizes or shapes.
PLT 465 x 10^9/L 150-450 High Some of the causes of a low blood platelet count include autoimmune diseases,
where the effected individual produces an antibody to his or her own platelets,
chemotherapy, leukemia, viral infections and some medicines
Due to the presence of infection, as a defense, platelets increased to help the
other cells in blood clotting if bleeding occurs.
MPV 6.5/L 7.0-11.0 Low Mean platelet volume measures the average amount (volume) of platelets. Mean
platelet volume is used along with platelet count to diagnose some diseases. If
the platelet count is normal, the mean platelet volume can still be too high or too
low.
PDW(Platelet 14.9 15.0-17.0 Low Indicates liver disease.
distribution width)
PCT(Procalcitonin) 0.302% 0.108-0.282 High Procalcitonin (PCT) Serum Levels for Rapid Detection of Systemic Bacterial
Infections.

COMPLETE BLOOD COUNT August 5, 2010 (6:07pm)

Examination Resul Reference Significance Implication

t range
Differential count
Neutrophils 16.7 11.4-14.5s High Presence of infection from bacteria or accumulation of bacteria in the
Lymphocytes 12.7 11.4-14.4s Normal liver.
Midcells 1.29
Eosinophils 62.8% Play a crucial part in the killing of parasites (e.g. enteric nematodes)
because their granules contain a unique, toxic basic protein and
cationic protein (e.g. cathepsinreceptors that bind to IgE are used to
help with this task
7
 Atypical cells 32.1 26-38 Normal Can be found almost anywhere in the body.
It can be caused of inflammation and infection.
Brand/Stabs 32.9 31.1-35.3s Normal

CLINICAL CHEMISTRY RESULT August 3, 2010 (4:14pm)

Test name Result Reference range Significance Implications

Sodium 132.9mmol/L 136-145 Low Low Na is due to decreased sodium intake and may relate to
vomiting which the patient manifests.
Potassium 4.1mmol/L 3.5-5.1 Normal Used to evaluate an electrolyte imbalance.
AST(Aspartate 39u/L 15-37 High It indicates liver disease which is present to the patient,
aminotransferase) especially when the small abdominal masses, fluid-filled
cysts and gallstones are present.
ALT (Alanine 52u/L 30-65 Normal Screens for liver damage by measuring the amount of an
aminotransferase) enzyme found mostly in the liver.
Used to evaluate a patient who has symptoms of a liver
disorder. Some of these symptoms include jaundice,
vomiting, and abdominal pain.
-It is normal in the patient’s condition due to the actions of
medications and the natural defense of the body.
Alkaline 814u/L 50-136 Normal Alkaline Phosphate an enzyme related to the bile ducts;
Phosphate often increased when they are blocked and also used to
screen for or monitor treatment for a liver.

URINALYSIS August 4, 2010

Test name Result Reference range Significance Implications

PHYSICAL
EXAMINATION:
Color: Amber Pale to dark Normal Normal, fresh urine is pale to dark yellow or amber in color and clear.
yellow or amber Normal urine volume is 750 to 2000 ml/24hr.
Appearance: Slightly Turbid Turbid Normal Normal color of urine varies from colorless to dark yellow. Certain foods
may stain it. Cloudy urine or urine with a high level of sediment may be
present in cases of urinary tract infection. Used to diagnose infections
and other urinary problems.

8
CHEMICAL
EXAMINATION:
pH 6.0 5.0 to 9.0 Normal Normal urine pH ranges from 5.0 to 9.0. Any urinalysis values outside of
that range can indicate a problem with acidity or alkalinity. If the PH
level of the urine is low, the urinalysis values for nitrates can be affected.
Low pH can lead to a false negative for nitrites, which means that nitrites
won't show up on the urinalysis even if they are present.
Specific gravity 1.030 1.002 and 1.035 Normal Any measurement below the normal range indicates hydration and any
measurement above it indicates relative dehydration.
Sugar Negative Negative Normal Glucose is not normally present in urine. When glucose is detectible, the
condition is called glycosuria.
Protein Negative Negative Normal The protein test pad usually measures the amount of albumin in the
urine. Normally there will not be detectable quantities of the protein
albumin.
MICROSCOPIC
EXAMINATION:
Pus cells 1-3/hpf 1-3/hpf Normal - An increased in amount indicates infections.
RBC None - Normal - This test is used to detect hemoglobin in the urine (haemoglobinuria).
Hemoglobin is an oxygen-transporting protein found inside red blood
cells (RBCs). Its presence in the urine indicates blood in the urine
(known as haematuria). The small number of RBCs normally present in
urine usually results in a “negative” test.

Yeast cells None - Normal Yeast cells may be contaminants or represent a true yeast infection. They
are often difficult to distinguish from red cells and amorphous crystals
but are distinguished by their tendency to bud.
Bacteria None - Normal Presence of bacteria indicates infection.
Epithelial cells Rare - Normal Epithelial cells are commonly seen in urine. Epithelial cells are
commonly excreted as the urine pass by at the ureters, urinary bladder
and urethra. But increased amount of it indicates kidney problems.
Mucus thread Many - Normal This is a common finding in urine since the entire urine system is filled
with mucus.
Amorphous materials Occasional - Normal This is abnormal finding in urine if too much and is only significant in
(urates) cases of renal stones.

9
FECALYSIS August 5, 2010

PHYSICAL EXAMINATION:
Color: Yellow
Consistency: Soft
MICROSCOPIC EXAMINATION:
Pus cells: 0-3/hpf
RBC: 0-2

REMARKS: with ova/parasites

IX. MEDICAL DIAGNOSIS

- Right Hepatic Abscess T/C Amebic

10
11
XI. TREATMENT/MANAGEMENT
A. DRUG STUDIES

12
 Trade and Classification Indication Mechanism of Action Side Effects Nursing Interventions
Generic Names of Drugs
Assessment:
Flagyl Antibiotic INTRA-ABDOMINAL >Reduced to a product which CNS; headache, dizziness, 1. History :hypersensitivity to
INFECTIONS, including interacts with DNA to cause a anxiety, metronidazole or any of its
Metronidazole peritonitis, intra-abdominal loss of helical DNA structure components;
abscess, and strand breakage resulting 2. Physical: abdominal
ORDER: and liver abscess, caused by in inhibition of protein GI: abdominal pain, examination
IV 500 mg, q8 Bacteroides species synthesis and cell death in nausea, vomiting, loss of
susceptible organisms. appetite Interventions:
Flagyl should be used only to 1. –Avoid contact between the
treat or prevent infections drug and aluminum in the infusion
that are proven or strongly set.
suspected to be caused by 2. Have regular medical follow-up
bacteria. visits.
3. Report severe headache,
Amebiasis. FLAGYL is worsening of symptoms.
indicated in the treatment of
acute intestinal amebiasis Teaching points:
(amebic 1. May be taken with food to
dysentery) and amebic liver minimize stomach upset
abscess. 2. Have regular medical follow-up
visits.
These side effects may occur:
Dizziness (avoid driving or
performing hazardous tasks);
headache (request medications);
nausea, vomiting, (maintain proper
nutrition
3. Report severe headache,
worsening of symptoms.

Ultram NSAID >Tramadol is used to treat
moderate to severe pain.
Tramadol >Tramadol extended-release
is used to treat moderate to
ORDER: severe chronic pain when
IV 300 mg q8 treatment is needed around
the clock.
Anti-inflammatory and
analgesic activity; inhibition
of ascending pain pathways,
altering the perception and
response to pain.
CNS: headache, dizziness, Assessment:
somnolence, fatigue, 1. History: renal impairment,
dizziness, stimulation, impaired hearing, allergies,
restlessness hepatic, lactation, pregnancy
2. Physical: orientation, reflexes,
GI: Nausea, vomiting, peripheral sensation,
dyspepsia, GI pain,
diarrhea, constipation, Interventions:
13 1. Be aware that patient may be at
Neuromuscular and risk for CV events, GI bleeding,
skeletal: weakness renal toxicity, monitor
 B. IV FLUIDS
Classification of the
Component of the Fluids
D5LRS
-sodium chloride, potassium
chloride, calcium chloride, and
sodium lactate in distilled
water.
FRESH FROZEN PLASMA
-coagulation, fibrinolytic and c
omplement systems;
the proteins that
maintain oncotic pressure and
modulate immunity; and other
proteins that have diverse
activities. In
addition, fats, carbohydrates a
nd minerals are present in
concentrations similar to those
in circulation
Indication
Fluids
This solution is indicated as a
source of electrolytes, calories
Hypertonic
and water for hydration.
FFP transfusion is indicated in
patients with documented
coagulation factor deficiencies
and active bleeding, or who are
about to undergo an invasive
procedure.
FFP is efficacious for treatment
of deficiencies of factors II, V,
VII, IX, X, and XI when specific
component therapy is neither
available nor appropriate.
Effects/Uses Significance
1. Provides electrolytes and Increases the interstitial space
calories, and is a source of osmolarity which then causes
water for hydration. fluid to leak out of the cells.
2. It is capable of inducing
diuresis depending on the
clinical condition of the
patient.
1. treatment of deficiencies
of coagulation proteins for
FFP contains the major plasma
which specific factor
proteins, including the labile
concentrates are unavailable
coagulation factors (V and
2. indicated in patients with
VIII), but in clinical practice
documented coagulation
other blood components or
factor deficiencies and active
derivatives usually provide
bleeding, or who are about to
greater efficacy.
undergo an invasive
procedure
14
 XII. NURSING DIAGNOSIS

01. Severe Pain related to tissue trauma secondary to disease process

02. Hyperthermia related to disease process

03. Imbalanced Nutrition: Less than body requirements related to poor appetite and nausea and
vomiting

04. Risk for Injury:Fall related to dizziness and body weakness

05. Risk for Deficient Fluid Volume related to effects of prolonged fever, diarrhea and

vomiting

06. Self Care Deficit: Bathing/hygiene related to musculoskeletal impairment

07. Activity Intolerance related to weakness and immobility

08. Impaired Walking related to paralysis of the right extremity

PRIORITIZATION:

1. Severe Pain related to tissue trauma secondary to disease process

2. Hyperthermia related to disease process

3. Imbalanced Nutrition: Less than body requirements related to poor appetite, nausea and
vomiting
4. Risk for Injury:Fall related to dizziness

5. Risk for Deficient Fluid Volume related to effects of prolonged fever, diarrhea and vomiting

15
1. SEVERE PAIN related to tissue trauma secondary to disease process.
Assessment Explanation of the Problem Objectives Nursing Rationale Evaluation
Interventions

S > “Nasakit idtoy.” The patient was diagnosed STO> After 2 hours of Dx> Assessed > Provides data about STO> Goal fully met.
referring at the right with right hepatic abscess rendering effective PQRST scale of intensity of pain and The patient verbalized a
upper quadrant of the which is categorized to be nursing interventions, the pain. helps deter t how the decrease in the rate of
abdomen rated as 7/10 in under bacterial causes. The patient will verbalize a patient reports mine pain from 7/10 to 3/10
a scale of 1-10 (1 as the infecting organisms now decrease in the rate of effectiveness of therapy. considered as mild pain.
lowest and 10 as the reach the liver through biliary pain from 7/10 to 3/10. And pain is a subjective
highest). And the pain system. Here, most bacteria Where 1-3, is considered experience and must be
occurs intermittently at are destroyed promptly but as mild pain, 4-6 as described by the client in
intervals of 3-4 hours. some gain a foothold. The moderate pain and 7-10 as order to plan effective
Pain described as severe bacterial toxins then destroy severe pain. treatment.
dull pain. the neighboring liver cells
which now results to damage > Assessed vital > To monitor the
to tissues. This tissue trauma signs. functions of the body and
O > Guarding of may now trigger the release of the signs reflect changes
abdomen noted chemical mediators such as in function that otherwise
> Grimacing noted prostaglandin and irritate LTO> After 2 days of might not be observed. LTO> Goal fully met,
> Weakness noted nerve endings. Furthermore, rendering effective because the patient
> prefers lying on bed prostaglandin enhances the nursing intervention, the > Observe for > gives information on verbalized an absence of
> with limited pain- provoking effect of patient will verbalize an nonverbal cues the severity of pain if the pain as evidenced by the
movements bradykinin. In response, there absence of pain as indicating the level patient is able to tolerate following:
> Needs assistance in is an increased sensitivity to evidenced by the of pain the pain or not. a. patient able to move
doing ADLs pain as the patient manifests. following: freely
a. Patient does not Tx> Promoted deep > Relaxation techniques b. patient able to
report any feelings of breathing exercises help reduce skeletal perform ADL
pain or discomfort. muscle tension which independently
A> Severe pain related b. Individualized will reduce the intensity
to tissue trauma interventions for of pain.
secondary to disease relief of pain.
process. >Created a quiet, > Comfort and a quiet
non-disruptive atmosphere promote a
environment with relaxed feeling and

16
dim lights and permit the client to focus
comfortable on the relaxation
temperature when technique rather than
possible. external distraction.

> Provided comfort > To promote non-

measures like touch, pharmacological pain
repositioning. management and to
provide comfort

>Administered >Tramadol inhibits

Tramadol as reuptake of
prescribed norepinephrine,
serotonin and enhances
serotonin release. It
alters perception and
response to pain by
binding to mu-opiate
receptors in the CNS.

Edx> Encourage > To further assess the

verbalization of patient’s condition and to
feelings relieve anxiety felt

> To promote muscle

> Encouraged to do and generalized
breathing exercises relaxation which helps to
and techniques reduce skeletal muscle
tension that will decrease
the intensity of pain.

17
>Encourage patient > Non pharmacologic
to do diversional method of controlling
activities such as pain wherein it can
reading, watching increase the release of
and music therapy. endorphins and enhance
the therapeutic effects of
pain relief medications

> Encourage patient > To decrease intra-

to change position abdominal pressure that
from time to time will contribute to reduce
and avoiding sitting the intensity of pain.
within a long
duration

18
2. HYPERTHERMIA
Assessment Explanation of the
Problem
Hepatic Abscess is
considered to be caused by
S> “Napudot ti riknak” exposure to
microorganisms especially
by bacteria that had
reached the liver via the
O> Febrile with a portal circulation. As a
temperature of 38.4 result of bacterial invasion,
>Flushed skin inflammatory process is
>hot to touch. stimulated. These may now
>Restlessness noted cause vasodilation and
>chills noted leakage of plasma fluids
>Diaphoresis noted containing white blood
>With good skin turgor cells. These WBCs will
now migrate to the site of
A>Hyperthermia r/t injury and release
disease process endogenous pyrogenic
cytokines. These cytokines
will now reach the
hypothalamus and promote
the synthesis and secretion
of Prostaglandin E2. In
response, these PG E2
increases the thermostatic
set point than the normal
range. Hence,
Hyperthermia results.
Objectives Nursing Interventions Rationale Evaluation
STO: After 1 hr. of Dx>Monitor core >To help determine STO: Goal fully met
nursing temperature changes from the since after 1 hour of
interventions, temperature and nursing
the patient’s interventions needed. interventions, the
temperature will >Assess hydration status >To monitor possibility of patient’s temperature
decrease from 38.4 and fluid loss dehydration and excessive decreased to 37.7
degree Celsius to at fluid loss by sweating. degree Celsius
least 37.8 degree
Celsius.
Tx>Promote surface >To decrease
cooling by means of Temperature by means
tepid sponge bath. through evaporation and
conduction.
>Loosen patient’s >To minimize body
clothings temperature and promote
heat loss by radiation and
LTO: After 8 hours conduction. LTO: Goal fully met
of nursing since after 8 hours of
interventions, the >To reduce metabolic nursing
patient will manifest >Maintain bedrest demands and oxygen interventions, the
an absence of fever as consumption patient manifested
evidenced by a an absence of fever
temperature within >To reduce patient’s as evidenced by a
the normal range. >Administer temperature and fast temperature of 37.3
Antipyretics as recovery. degree Celsius
prescribed which is within the
normal range.
Edx> Instruct significant
19
others to continue > to promote rapid core
providing TSB as cooling
needed

>Instruct on ways to
protect self from > to minimize use of
excessive heat such as excessive clothing that
reduced clothings may contribute to
increased temperature.

20
3. Risk for injury/fall related to dizziness and body weakness
Assessment Explanation of the Objectives Nursing Interventions Rationale Evaluation
Problem
The patient’s lab STO> After 2 hours of Dx> Assess patient’s >The stated parameters are STO> Goal fully met
results for CBC nursing interventions, response to activities, helpful in assessing if after 2 hours of
S> “Maul-ulaw ak no reveals that he has a the patient/SO will: noting excessive physiological responses to the nursing interventions,
maminsan” fatigue, weakness, stress of activity
low RBC, the patient/SO will:
1. Demonstrate diaphoresis,
hemoglobin and dizziness/syncope
behavior necessary to 1. Demonstrate
hematocrit count protect self from behavior necessary
O> with decreased range related to potential potential injury such > Note changes in > Changes may indicate to protect self from
of motion bleeding secondary to as mentation or level of decreased cerebral perfusion potential injury such
tissue trauma. Having a. Assisting the consciousness secondary to hypoxemia as
> responsive and patient with
low blood a. Assisting the
cooperative with nursing exercises and patient with
components indicates
interventions rendered ambulation > Identifies probable exercises and
that there would be > Review functional functional impairments and
b. Reduction of ambulation
> with dizziness upon decreased oxygen- extraneous stimuli ability and reasons for influences choice of b. Reduction of
exertion noted carrying compounds and provide weakness and fatigue interventions extraneous
in the body, and the comfort stimuli and
> needs assistance in organs and tissues measures(calm provide comfort
ADL’s don’t work well. and restful > Evaluate knowledge > Indicator of need for measures(calm
environment) of needs or injury information, assistance with and restful
There would be
> with decreased muscle c. Have rest preventions motivation making positive changes, environment)
fatigue, or a feeling to prevent further promoting safety and sense of
strength noted periods and c. Have rest
of weakness or stopping the injury security periods and
> capillary refill time of diminished physical activity when stopping the
1-2 sec and mental capacity. experiencing activity when
Additional symptoms fatigue > Monitor lab values > To identify presence of risk experiencing
> CBC result reveals low include diminished 2. Modify (CBC) factors that may potentiate fatigue
RBC, Low Hgb, Low environment as injury 2. Modify
ability to perform
Hct. Count. indicated to enhance environment as
daily functions and
safety by keeping all indicated to enhance
21
 possibly dizziness. necessary objects Tx> Assist with > Strengthens muscles safety by keeping all
within patient’s reach, passive/active range of necessary objects
A> Risk for injury/fall In regards, the patient placing pillows beside motion exercises within patient’s
related to dizziness and is at risk for injury the patient. reach, placing
body weakness due to dizziness and > Maintain a safe > Reduces accidental injury pillows beside the
malaise. environment by patient.
keeping all necessary
objects within patient’s
LTO> After 72 hours reach, placing pillows
of nursing beside the patient
interventions, the LTO> Goal fully met
patient will be free > Assist with activities/ > Activity depends on if after 72 hours of
from injury/fall, report progressive ambulation individual situation but usually nursing interventions,
progresses slowly according to the patient will be
improved sense of
tolerance free from injury/fall,
energy, achieve
optimum strength, and report improved
> Reduce extraneous
perform activities with stimuli and provide > Provides calming effect, sense of energy,
decreased fatigue and comfort measures such decreases adverse achieve optimum
weakness. as quiet environment, physiological response strength, and perform
gentle touch and activities with
therapeutic approach decreased fatigue and
weakness.
> Accept when patient > Nonjudgmental acceptance
is unable to do of patient’s
activities capability/incapability
provides opportunity to
promote independence while
supporting fluctuations in level
of required care

> Do necessary >Allow for extended periods

tasks/interventions of uninterrupted rest
quickly as possible

22
Edx> Educate on > Reduces risk of injury and
proper body mechanics increases likelihood of patient
for participation in involvement in progressive
activities activity

> Instruct on the > Reduces demand for more

importance of rest energy
periods as appropriate

> Encourage > Patient participation

participation in ADL’s promotes independence and
within individual sense of control, enhances
limitations muscle strength and endurance

> Stress need for > Pushing self beyond

stopping activity when individual physical limits can
experiencing fatigue result in excessive/prolonged
fatigue

> Encourage use of > Promotes relaxation and

diversional activities conserves energy, redirects
such as listening to attention and may enhance
music, watching TV coping
and reading
books/magazines

> Instruct SO to assist > Aids the patient to do the

the patient with activity/exercise and
passive/active range of strengthens muscles with
motion exercises and guidance
with activities/
progressive ambulation

> Emphasize the > Good nutrition can

importance of good counteract the loss of strength,

23
nutrition. Encourage on it is also important to get
eating iron rich foods enough iron because iron
such as dark green builds red blood cells, and
leafy vegetables, beef, vitamin C increases absorption
organ meats, pork, of iron
poultry, fish, eggs,
dairy products, bread,
pasta, and fruits
(vitamin C rich).

24
4. IMBALANCED NUTRITION: Less than body requirements
Assessment Explanation of the Problem
S> “Awan ti ganas ko The patient was
nga mangan, kar-karo no diagnosed with Right
sumakit jay tiyan ko” Hepatic Abscess which is a
pus-filled mass inside or
attached to the liver as a
result of infection by
O> weakness noted bacteria, protozoa, or other
> non- ambulatory agents.
> with dry mucous The patient then
membranes complained of dull
> body weight under abdominal pain and
ideal for height and frame tenderness in the right upper
> BMI= 17 quadrant of his abdomen;
> RBC=3.56 x 10.12/L however other manifestations
also occurred, wherein the
A> Imbalanced patient had experienced
nutrition: less than nausea and vomiting, poor
body requirements appetite and had also weight
related to poor loss.
appetite and nausea Thus, leading now for
and vomiting the patient to have an
imbalanced nutrition which
is less than his body
requirements.
Objectives Nursing Rationale Evaluation
Interventions
STO> After 5 hours of Dx> Monitored vital > Obtained baseline STO> Goal partially
effective nursing signs and recorded data. Note if there is a met. After 5 hours of
interventions, the patient sudden change in vital effective nursing
will verbalize and signs interventions, the
demonstrate proper patient verbalized
selection of foods/meals > Assessed > To establish baseline proper foods/meals
that will achieve a patient’s weight parameters that achieves a
healthy and balanced balanced nutrition,
nutrition such as: > Monitored/ > Many psychological, but was unable to
a. eating low-fat explored attitude psychosocial and demonstrate such
foods towards eating/foods cultural factors behavior.
b. adequate caloric determine the type,
intake amount and
appropriateness of food
consumed
> Monitored > Laboratory values
laboratory values indicates nutritional LTO> Goal not met.
well-being/ After 3 days of
deterioration (e.g. effective nursing
LTO> After 3 days of Decreased RBC count interventions, the
effective nursing indicates anemia and patient was unable to
interventions, the patient decreased resistance to weigh within 10% of
will weigh within 10% infection) and serves ideal body weight or
of ideal body weight or as a basis as to what to regain his normal
regain his normal body give body weight
weight
> Monitored Input > To assess patient’s
25
and Output appetite

Tx > Assisted patient > To facilitate eating

with meals as needed

> Promoted > To enhance eating

pleasant and relaxing
environment,
including socialization
when possible
Recommendations:
> Discouraged > To avoid decrease in 1. Continue health
beverages that are appetite, early satiety teachings regarding
caffeinated and and gastric irritation the ff:
carbonated a. importance
of healthy and
>Promoted foods such > to decrease nausea or nutritious foods
as toast, crackers, dry feelings of disgust 2. Encouraged SO
cereal before arising to prepare proper
when nausea occurs foods, such as:
a. low-fat foods
Edx> Encourage to eat >So that the stomach b. high- caloric
small meals spaced does not feel foods
throughout the day excessively full c. Iron and Vit.
instead of large meals C. rich foods

> Emphasized to > To promote

the patient the understanding and
importance of well- acceptance
balanced , nutritious
intake

> Encouraged SO > To promote healthy

to promote intake of eating habits
high-caloric and low-

26
fat, iron and Vit.C rich
foods
> Unpleasant
>Advised SO to environment may have
minimize unpleasant a negative effect on
environment (odors, appetite
sights, etc)

27
5. RISK FOR FLUID VOLUME DEFICIT
Assessment Explanation of the
Problem
S.”Agburisak ken The patient’s gastric
agsarwaak pay’as mucusa is irritated and
verbalized by the pt. inflamed causing him
now to vomit. Also
O>loose watery toxins released by
stools noted 3-5 causative
times microorganisms irritates
>diaphoresis noted the mucosa, thereby
>vomited twice stimulates secretion of
>vomited described water or electrolytes
as liquid with resulting to destruction
minimal contents of the intestinal
>With good skin epithelial cells. This then
turgor results to a local
>With capillary inflammation and
refill of 1-2s becomes the cause of
diarrhea with minimal
vomiting episodes that
A>Risk for fluid the patient experiences.
volume deficit Additionally, the patient
related to effects of experiences intermittent
prolonged fever associated with
fever,diarrhea and diaphoresis. In a
vomiting. phenomena, this may
lead to deficit fluid
volume if it continues to
progress due to
excessive fluid loss.
Objectives Nursing Interventions Rationale Evaluation
STO:After 8 hours of Dx: STO:Goal met if:
effective nursing >Note possible >To know the factors that After 8 hours of effective
interventions, the conditions that may lead causes fluid loss nursing interventions, the
patient will be able to to fluid volume deficit patient will be able to to
to identify individual identify individual risk
risk factors and >Assess skin turgor/oral >This may indicate fluid factors and appropriate
appropriate mucus membrane status interventions
interventions
>Closely monitor vital >Abnormal vital signs
signs may suggest orthostatic
hypotension, tachycardia
and fever.
>Monitor I and O >To ensure accurate LTO:Goal met if:
balance picture of fluid status After 2 days of effective
LTO:After 2 days of nursing interventions the
effective nursing Tx: patient will be demonstrates
interventions the >Allow adequate time for >Helps the client increase behaviors or lifestyle
patient will be able to eating and drinking food and fluid intake changes to prevent the
demonstrate behaviors development of fluid volume
or lifestyle changes to >Limit fluids that tend to deficit
prevent the exert diuretic effect like >To prevent further fluid
development of fluid caffeine and alcohol loss.
volume deficit.
>Offer fluids >Aids in replacing fluid
loss
28
Edx:
>Encourage oral intake
of fluids as tolerated >Aids in fluid loss

>Discuss the risk factors >For the client to

for fluid volume deficit ascertain appropriate
actions to prevent further
fluid loss

>Advise pt. to increased >To replace fluid loss

intake of high water
content foods such as
popsicles,gelatin,soup
and watermelon.

29
XIII. DISCHARGE PLAN

CRITERIA HEALTH TEACHINGS

>Can eat fat as tolerated but should keep carbohydrate intake low and avoid
concentrated sources of carbohydrates.
A. Diet
> Low fat, Iron and Vit. C rich foods
>Avoid beverage drinking that may aggravate liver damage.

>Instruct SO to massage the affected arm and leg

B. Activities >Instruct to continue massaging paralyzed extremity to promote circulation.
>Encourage gradual increase of activity as tolerated and to protect self from
injury

>Advise to continue taking his medications especially antibiotics prescribed

C. Medications >Medications should be taken according to the doctor’s order: dosage, and
frequency

> Report Signs and symptoms to physician: persistent diarrhea, recurrent

abdominal pain and fever.
D. Others >Report possible bleeding tendencies
>Provide symptom management

XIV. CONCLUSIONS AND RECOMMENDATIONS

The liver is one of the most complex organs in the body. It is located on the right side of the
abdomen. The liver is separated into a right and left lobe by the falciform ligament. The right lobe is
much larger than the left lobe. The working cells of the liver are known as hepatocytes. Hepatocytes
have a unique capacity to reproduce in response to liver injury. Although the liver's ability to react to
damage and repair itself is remarkable, repetitive insults can produce liver damage and failure. Liver
disease had accounted to a large number due to certain agents. One particular disease includes liver
abscess.

Liver Abscess had been linked to develop from the gastrointestinal tract. Whenever an
infection develops along the GI tract, the infecting organisms may reach the liver through portal
venous system. Most bacteria are destroyed promptly, but occasionally gain a foothold. The bacterial
toxins destroy the neighboring liver cells, and the resulting necrotic tissue serves as a protective wall
for the organisms. Meanwhile, leukocytes migrate into the infected area. The result is an abscess cavity
full of a liquid containing living and dead leukocytes, liquefied liver cells and bacteria. This abscess
can be serious and lead to gangrene and permanent organ damage if they are not recognized and treated
promptly.

As a nurse who happen to engage with this kind of liver problem must knowledgeable enough
in regards to the disease process and its management. A thorough assessment on how the patient feels
and manifests must be performed in order to identify any problems that may arise and to confirm the
problem. Nursing management depends on the patient’s physical status and the medical management
that is indicated. Antibiotics must be maintained as prescribed and certain surgical management such
as drainage is a matter of choice. It is important to recognize the issues shared by liver abscess and to
devise strategies to assist them in achieving independence after treatment.

30
XIV. LIST OF REFERRENCES

A. Karch, Amy M. (2007). “Lippincott’s Nursing Drug Guide”. Philadelphia:

Lippincott Williams &Wilkins.

B. Matassarin, Esther J. (1992). 2nd Ed. “Review of Practical Nursing for NLEX-
PN”. West Philadelphia: W. B. Saunder’s Company.

C. Nettina, Sandra M. (2001). 7th Ed. “The Lippincott Manual of Nursing

Practice”. 530 Walnut Street, Philadelphia: Lippincott Williams &
Wilkins.

D. Quiambao, Josie U. (2002). 1st Ed. “Medical- Surgical Nursing: Concepts

and Clinical Application; A reference Book and Study Guide”. 24
Panghulo Road Malabon, Philippines: Guiani Prints House.

E. Suzanne C. Smeltzer & Brenda G. Bare (2004). 10th Ed. “Brunner &
Suddarth’s Textbook of Medical and Surgical Nursing”. 530 Walnut
Street, Philadelphia: Lippincott Williams & Wilkins.

F. Thibodeau, Gary A. & Kevin T. Patton (2004). 5th Ed. “Anatomy and
Physiology”. Philippines: Elsevier (Singapore) Pte. Ltd.

G. www.cancer.gov

H. www.fpnotebook.com

I. forum.wordreference.com

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XV. APPENDICES

B. INTERVIEW GUIDE

1. Statement of general health before illness: How had you been feeling before this problem
started?

• “Nariknak ket bigla sinmakit jay tiyan ko ditoy kanawan nga banda.”

2. Date of onset: When did it started?

• “Nagrugi nga nariknak daytoy sakit idi mga.last weeks ti June”

3. Characteristics of onset: What was it like when it started?

• “Han met unay nasakit jay imuna ngem pasubli-subli, ket idi bimayag ket talga nga
nagsakit nga pirmi”

4. Severity of symptoms: How would you rate the pain on a scale of 1-10 with 10 being the
worst?

• “Han met unay nasakit jay imuna, idi lang mga July nga talaga nga nasakit nga pirmi.
Nu irate ko ti sakit na nga talaga ket mga ten over ten”.

5. Course since onset: How often does the attack or pain occur? Have the symptoms changed
since the first attack?

• Idi nga diyay ket han unay sakit na, ngem idi July kimaro ti sakit na isu nga kuna piman
ni baket nga apan kami agpacheck-up jay ospital. Ngem idi adaak ospital ket umawan-
umada ti sakit na, isunga kunak piman nga agawidak na lang ta kasla met hanan
agbal-baliw”.

6. Associated signs and symptoms: Have you noticed any other changes in your health or the way
you feel?

• “Mariknak ngay ti bagik nga kumapsotak, santo kinmut-tong ak nga pirmi, limaw-law
garud dagitoy badok”.

7. Aggravating or relieving factor: is their anything that seems to make you feel better or worse?

• “Ado dagijay in-inted da nga agas kanyak idi ijay ospital ket maikat met piman ti sakit
na ngem ada latta ti pagkaruan na ” .

8. Effect on activities: Has this stopped you from going to work or kept you awake?

32
 • “Wen ,ngem nabayagak met kitdi nga sinmardeng nga agtratrabaho ta haan kon gamin
maikuti daytoy kagudwa ti bagik ta n a-istoke gaminen.”

9. Treatments tried and results: Have you taken any medications or tried any treatments? If so,
what happened when you took the medications or after the treatment?

“Idi naconfine ak ijay ospital ado inted da nga agas, pain reliever kanu ngem dik talaga
malagip nagan na dagijay inted da nga agas”.

10. What do you think caused this problem?

• “Ti amok lang ket jay panagsigsigarilyok ken jay panag-inom ko ti arak”.

33