In partial fulfillment of the Requirements In

NCM-101 RELATED LEARNING EXPERIENCE A CASE STUDY On LIVER CIRRHOSIS At the ECHAGUE DISTRICT HOSPITAL

SUBMITTED BY: Ephraim Ablan Mary Aileen Asajar Dianne Melvin Buscagan Rosemarie Camposano Allyssa Marie Idorita Elaine Marjorie Figarola Neilborn Lutrania Korina Sirajani Maria Claudette Usita SUBMITTED TO: Abraham Nicolas, RN, MSN
(Clinical Instructor)

INTRODUCTION
Cirrhosis is a condition in which the liver slowly deteriorates and malfunctions due to chronic injury. Scar tissue replaces healthy liver tissue, partially blocking the flow of blood through the liver. Scarring also impairs the livers ability to

control infections remove bacteria and toxins from the blood process nutrients, hormones, and drugs make proteins that regulate blood clotting produce bile to help absorb fatsincluding cholesteroland fat-soluble vitamins

A healthy liver is able to regenerate most of its own cells when they become damaged. With end-stage cirrhosis, the liver can no longer effectively replace damaged cells. A healthy liver is necessary for survival. ETIOLOGY Cirrhosis is commonly caused by excessive drinking of alcohol, drug reactions, prolonged exposure to toxic chemicals, parasitic infections and repeated bouts of heart failure with liver congestion. CAUSATIVE AGENT Alcohol, drugs, toxins and infections, autoimmune hepatitis, Nonalcoholic fatty liver disease (NAFLD), chronic hepatitis C and Chronic hepatitis B and D

CLINICAL MANIFESTATION Compensated Intermittent mild fever Vascular spiders Palmar erythema (reddened palms) Unexplained epistaxis Ankle edema Vague morning indigestion Flatulent dyspepsia Abdominal pain Firm, enlarged liver Splenomegaly

Decompensated Ascites Jaundice Weakness Muscle wasting Weight loss Continuous mild fever Clubbing of fingers Purpura (due to decreased platelet count) Spontaneous bruising Epistaxis Hypotension Sparse body hair White nails Gonadal atrophy

REVIEW OF RELATED LITERATURE

The most important risk factor associated with liver cancer is cirrhosis, a condition that precedes 80 percent of all liver cancers. The most common cause of cirrhosis is chronic hepatitis B, a condition that afflicts about 10-12 percent of all Filipinos. Chronic Hepatitis B is the main reason liver cancer incidence in the Philippines is high. Other possible causes of cirrhosis are hepatitis C infection and alcoholism. The human liver is the largest single organ in the body and consists of parenchymal cells, which metabolize, detoxify, synthesize, and store nutrients. Normal functioning of these cells depends on their proper organization. Cirrhosis, the final common pathway for a variety of liver diseases, occurs when excessive fibrosis results in the conversion of normal liver architecture into structurally abnormal nodules.

 Cirrhosis is irreversible and can be life threateningit is a public health concern because of its associated mortality and morbidity. The only available and definitive treatment is liver transplantation. Cirrhosis is, however, preventable in most cases. The cumulative probability of clinical decompensation was 22% at 1 year and 54% at 3 years after cirrhosis developed. The cumulative survival rate was 92% at 1 year and 78% at 5 years in patients with compensated cirrhosis.

PATIENT PROFILE
Patient Name: Age: Sex: Address: Civil Status: Occupation: Religion: Birth Date: Birth Place: Date of Admission: C/c: Mr. MA 45 y/o Male Purok 2 Diaraw, Jones, Isabela Single Farmer Roman Catholic March 5, 1965 Burgos, Isabela August 17, 2010 Body weakness Noted sign of abdominal enlargement Conscious Attending Physician: Ma. Cristina A. Ventura

LABORATORY RESULTS
ABDOMINAL ULTRASOUND

The liver is enlarged with a liver span of at least 17.0cm. It shows coarse echotexture and lobulated margins. The intrahepatic and extrahepatic ducts are not dilated (CBD=45mm). Moderate amount of ascites is seen in the perihepatic, perisplenic, both paracolic gutters, and pelvic cavity. The gallbladder is minimally distended with suggestive tiny medium level echoes within. Pancreas and spleen are unremarkable. Only the proximal portion of the abdominal aorta is visualized. It is unremarkable with no aneurysms noted. Both kidneys are normal in size (RK=10.6 *5.1*5.2cm. LK=10,0*5.3*5.0cm) and parenchymal echogenicity. No stones or hydronepphrosis seen. Cortical thickness measures RK=9.0mm. LK=6.6mm. The urinary bladder is minimally distended. The wall is normal in thickness. REMAKS: HEPATOMEGALY WITH LIVER CIRRHOSIS MODERATE ASCITES MINIMALLY DISTENDED GALL BLADDER WITH CHOLESTEROLISIS STEPHEN ISIDRO MD Radiologist Ultrasound

HEMATOLOGY

Heb

PARAMETERS Male Female Male Female X109/L

NORMAL VALUES 140-70 120-60 .40-.51 .37-4.5 5.0-10.0

RESULTS 147

Interpretation polycythemia, congestive heart failure, obstructive pulmonary disease, high altitudes in anemia, hyperthyroidism leukemia, cirrhosis,

Hct

.44

WBC

15.4

Leukocytosis is an abnormal high WBC. Bacterial infections often cause leukocytosis by stimulating neutrophils to increase in number.

RBC X1012/L Platelet X109/L Neutrophils % Lymphocytes % Monocytes % Eosinophils % Band or Srab

140-440 55-65 25-40 2-8 1-3 2-5

85 15

60% to 70% ( in acute infections) 20% to 25% ( antibody reactions)

Mila Amor V. Reyes MD, FPSI Anatomic & Clinical Patho

GORDONS FUNCTIONAL PATTERNS

Before Hospitalization During Hospitalization Mr. MA doesnt told his SO (s) if It was July 2010 he started complaining the ever he got sick. enlargement of his abdomen. And reported he The patient perceive as long as he defecated for many times and he was rushed feel alright he consider his self to the hospital. healthy. Mr. MA is found of drinking alcoholic drinks even without Mr. MA had eat the food he wanted as order intake of food he stated that Sa by doctor that his diet as tolerated except the isang araw dalawang long-neck, day he had the ultrasound. emperador kasama ang mga kaibigan ko nag-iinuman as verbalized by the patient The patient experience loose bowel movement more or less 10X defecation/day. After voiding the patient experience dizziness Mr. MA is a farmer, verbalized by the patient nakakapagod talaga trabaho sa bukid, minsan madali akong mapagod The patient experience difficulty of sleeping, due every afternoon he drink alcoholic drinks with his colleagues. Mr. MA stays at his bed and gets up from his bed when he feel urge of defecation.

Health perception and health management

Nutritional metabolic Pattern

Pattern of elimination

Activity-Exercise Pattern

Sleep-rest pattern

The patient also experiences difficulty of sleeping due to the environment. The patient looks tiredly.

Cognitive-perceptual pattern

The patient is behaved especially when he is drunk. Never injured anyone especially when he is drunk.

The client feels dizzy after he defecated and feels uncomfortable.

Self perception-self concept pattern

The patient doesnt show any feelings of fear or anxiety. He jokes around as if nothing is wrong, but after defecating his mood change, he looks irritable and uncomfortable. The patient has a enlarge abdomen. He is uncomfortable with his appearance and his mobility The patient is the third child in six siblings, the patient stated the eldest and second eldest always done the family decision. So, he has no big responsibilities in the family. The patient verbalized that he is still single. The patient cope with his problem by drinking alcoholic drinks with his friends and doing his vices like smoking for the patient it helps in his problem. The patient is covert he solve problems by himself. He sleeps or lay on the bed to rest.

Role- relationship pattern

Sexuality-reproductive pattern Coping stress-tolerance pattern

Value-belief pattern

The patient is Roman Catholic. At their home they are oriented with their religion and according to the patient they have strong devotion.

NURSING HEALTH HISTORY

Patient MA verbalized that this is his first time to be hospitalized because before he never had been hospitalized. The common illness they may have are common colds, cough and fever. Present Medical History Was the date of confinement of August 17, 2010 the patient MA. According to the patient he observes the usual enlargement of his abdomen and frequent defecating so he was rushed to the hospital and admitted. Family Health History According to the patient the usual illness in their family are asthma and hypertension. RR: CR: 36cpm 128bpm BT: PR: 39.6 C 141bpm

Bowel Sounds 3spm

Abdomen:

33cn length 84cm width A grade 6 change smoker Alcoholic drinker

General appearance: the patient with D5W 1L at 16 hours hooked at left arm. The patient can tolerate sitting and lying position and infusing well but after the patient defecated he looks pale, discomfort and felt dizzy.

PHYSICAL ASSESSMENT
BODY PART ASSESSED SKIN TECHNIQUE USED Inspection Palpation Palpation Palpation NORMAL FINDINGS Varies from light to deep brown Uniform; within normal range Moisture in skin folds No abrasions or other lesions; freckles , some birthmarks, some flat and raised nevi When pinched, skin springs back to previous state ACTUAL FINDINGS Color : Light brown Skin temperature : warm Moisture: Slightly dry Presence of lesion and scars. INTERPRETATION NORMAL ABNORMAL due to increase of body temperature ABNORMAL due to dryness of the skin ABNORMAL due to interruption in skin integrity

Palpation

Good skin turgor

NORMAL

NAILS

Inspection Inspection Palpation

HEAD

Convex curvature; angle nail with 160 Highly vascular and pink Prompt return of pink or usual color(Generally less than 4 sec)

Angle nail 160 Color : Slightly pinkish

NORMAL NORMAL

Good blanch Capillary test

NORMAL

 Skull

Inspection Palpation

Rounded; smooth skull contour Smooth, uniform consistency; Absences of nodules or masses Canthus of the eye is approximately in line with the upper tip of the ear No infection or infestation Evenly distributed Thick hair and silky, resilient hair

Normocephalic ; smooth skull contour No masses, nodules and deppresions

NORMAL

NORMAL

Inspection

Canthus of the eye is approximately in line with the upper tip of the ear

NORMAL

SCALP

Inspection

Absence of infection or infestation Evenly distributed Thin hair and not brittle , slightly dry

NORMAL

HAIR

Inspection Inspection

NORMAL NORMAL

EYES EYEBROWS AND EYELASHES EYELIDS LACRIMAL

Inspection

Hair evenly distributed and symmetrically aligned

Inspection

Palpation

Skin intact; no discharges and discoloration No edema or

Normal outer, symmetrical with the outer eyebrow and eyelashes even distribution of hair with lesion on the upper part of the eye. Skin intact; no discharges and discoloration Not swollen/no tenderness

NORMAL

NORMAL

NORMAL

APPARATUS CONJUNCTIVA Inspection Inspection

tenderness ABNORMAL due to lack of oxygen Shiny, smooth and pink or red Colorless , shiny and smooth Black in color ; Pupil Equally Round, Reactive to Light and Accommodation Pale ABNORMAL due to liver disorder Yellowish or jaundice

SCLERA

PUPILS

Inspection

Black ; PERRLA

NORMAL

EARS

Inspection

Color same as facial skin

Color same as facial skin NORMAL

AURICLES

Palpation

NOSE

Mobile, firm and not tender; pinna recoils after it is folded Symmetric and straight Not tender; no discharge ; mucosa pink Not tender

Mobile, firm and not tender; pinna recoils after it is folded

NORMAL

Inspection Inspection

Symmetric and straight Not tender; no discharge ; mucosa red in the left nostril Not tender

NORMAL NORMAL NORMAL

FACIAL SINUSES

Percussion

MOUTH LIPS

Inspection

Dark brown

ABNORMAL due to smoking

 BUCCAL MUCOSA

Inspection

Uniform pink/brown color ; Pink color, moist, smooth, and soft

No sores and red color, moist, smooth, and soft

NORMAL

GUMS

Inspection

Dark brown gums

ABNORMAL due to smoking

TEETH

Inspection

Pink gums

(+) dentures at upper and lower gums ABNORMAL due to it may cause lesion

TONGUE

Inspection

GAG REFLEX PALATE AND UVULA Inspection Inspection NECK Inspection Palpation

32 teeth; smooth, white, shiny tooth enamel Pink color; cenral position, moves freely; no tenderness Present Light pink, smooth, soft palate; Lighter pink hard palate, more irregular texture; Uvula positioned in midline of soft palate Muscles equal in size; head centered Lymph nodes not

Red color; central position, moves freely; no tenderness; smooth with no palpable nodules Absent Red , smooth, soft palate; Red hard palate, more irregular texture Uvula positioned in midline of soft palate Muscles equal in size; head centered No scars and mass; no palpable lymph nodes; trachea is at the center

NORMAL

ABNORMAL it may indicate problems with glossopharyngeal NORMAL NORMAL NORMAL NORMAL NORMAL

THORAX (Anterior) ABDOMEN Auscultation

palpable

Vesicular and bronchovesicular

Clear breath sounds

NORMAL

Inspection

No evidence of enlargement of liver or spleen Audible sounds, absence of arterial bruits, absence of friction rub Tympany over the stomach and gas-filled bowels; dullness over the liver and spleen, or a full bladder

Auscultation

Has evidence of enlargement of liver or spleen; - Abdomen size: 33cm length and 84 cm width Bowel sound 3spm, RUQ

ABNORMAL due to unusual enlarge abdomen

ABNORMAL due to decrease of motility

Percussion

Dullness at 4 quadrant of the abdomen

ABNORMAL due to large dull areas

PERIPHERAL VASCULAR SYSTEM ARMS Palpation

Symmetric pulse volumes; Full pulsation

Presence of radial pulse and brachial pulse; no edema

NORMAL

REFEXES

 TRICEPS REFLEX PATELLAR REFLEX MOTOR FUNCTION FINGERS TO THUMB Rapidly touches each finger to thumb with each hand Percussion Percussion +2 normal response +2 normal response

+2 +2

NORMAL NORMAL

Normally touches each finger to thumb with each hand

NORMAL

ANATOMY
Vital organ present in vertebrates and some other animals. Reddish brown organ with four lobes with unequal in size and shape. Lies below the diaphragm in the thoracic region of the abdomen. Weighs 1.4-1.6 kg (largest internal organ). Connected into two large vessels, hepatic artery (carries blood from the aorta) portal vein (carries blood containing digested nutrients). The two blood vessels subdivide into capillaries which then lead to a lobule. FUNCTIONS Has major role in metabolism produces bile which is important to digestive process. Serves as storage of nutrients for later use or processed in various. Detoxification, protein synthesis, production of biochemicals necessary indigestion. It produces bile, an alkaline compound which aids in digestion, via the emulsification of lipids. Produces albumin the major osmolar component of blood serum. The liver synthesizes angiotensinogen, a hormone that is responsible for raising the blood pressure when activated by renin an enzyme that is released when the kidney senses low blood pressure. The liver is responsible for immunological effects- the reticuloendothelial system of the liver contains many immunologically active cells, acting as a 'sieve' for antigens carried to it via the portal system. The various functions of the liver are carried out by the liver cells or hepatocytes.

Biliary Terr The term biliary tree is derived from the arboreal branches of the bile ducts. The bile produced in the liver is collected in bile canaliculi, which merge to form bile ducts. Intrahepatic (within the liver) bile ducts, and once they exit the liver they are considered extrahepatic (outside the liver). The cystic duct from the gallbladder joins with the common hepatic duct to form the common bile duct.

Synthesis: protein produce and secreted water o A large part of amino acid synthesis o The liver performs several roles in carbohydrate metabolism: Gluconeogenesis (the synthesis of glucose from certain amino acids, lactate or glycerol). Note that humans and some other mammals cannot synthesize glucose from glycerol. Glycogenolysis (the breakdown of glycogen into glucose ) Glycogenesis (the formation of glycogen from glucose) (muscle tissues can also do this) o The liver is responsible for the mainstay of protein metabolism synthesis as well as degradation

NURSING CARE PLAN

ASSESSMENT Subjective: Mainit ang pakiramdam ko as verbalized by the patient. DIAGNOSIS Hyperthermia r/t increased metabolic rate manifested by increase in body temperature above normal range. PLANNING Within an hour of nursing interventions the clients body temperature will decrease at 37.5C. INTERVETION The nurse will: Monitor vital sign. To have baseline of the patients vital sign For heat loss by evaporation and conduction. For heat loss by radiation and conduction. RATIONALE EVALUATION Within 1 hour of nursing interventions the patient body temperature decreases as evidenced by a body temperature of 37.5C and the client reported being comfortable -GOAL MET-

Provide to the client a TSB.

Objective: RR: CR: BT: PR:

36cpm 128bpm 39.6C 141 bpm

Promote surface cooling by means of removing excess linens and dressing, if there is. Maintain bed rest

To reduce metabolic demand. For a restful environment for the patient. To treat underlying condition.

Promote a cool and calm environment

Administer antipyretics as ordered by the doctor

Administer replacement fluids and electrolytes Provide high-calorie diet Discuss importance of adequate fluid intake

To support circulating volume and tissue perfusion To meet increased metabolic demands To prevent dehydration

ASSESSMENT Subjective: Minsan hindi ako makahinga lalo na pag busog ako as verbalized by the patient. Objective: Increase metabolic rate CR: 128bpm RR: 36cpm Shortness of breath observable when he speak

DAGNOSIS Impaired spontaneous ventilation r/t compression of diaphragm manifested by shortness of breath, increase cardiac rate and increase respiratory rate

PLANNING

INTERVENTION

RATIONALE For baseline data To measure work of breathing. To monitor if there is complication may occur.

EVALUATION Within an hour of nursing interventions the patient establish effective respiratory pattern via individual ability as evidenced by decrease in respiratory rate and cardiac rate. -GOAL MET-

Within an hour of The nurse will: nursing interventions the Monitor vital sign client will Reestablish effective Assess spontaneous respiratory pattern respiratory pattern, via individual ability noting rate, depth, as evidenced by rhythm, symmetry of decrease in chest movement, use respiratory rate of accessory muscles. and cardiac rate Elevate head of bed if possible

To alleviate dyspnea and to the facilitate oxygenation To maximize respiratory function

Coach client to make slower, deeper breaths, practice abdominal breathing, and assume position of comfort. Instruct client in use of energy-saving techniques during care activities.

To limit oxygen consumption

ASSESSMENT Subjective: Lagi akong nagdudumi as verbalized by the patient Objective: More or less 10 times defecation per day Bowel sound: 3 sounds/min

DIAGNOSIS Altered elimination pattern r/t compression of large intestine and increase of bilirubin manifested by More or less 10 times defecation per day.

PLANNING

INTERVENTION

RATIONALE

EVALUATION After an hours of nursing intervention the client had established partial pattern bowel functioning as evidenced by decrease number of defecation, 7 times of defecation per day. -GOAL MET-

Within an hour of The nurse will: nursing intervention the Monitor vital sign client will reestablish normal Ascertain onset and pattern of bowel pattern of diarrhea, functioning as noting whether acute evidenced by or chronic. decrease of defecation per day Restrict solid food at least 7 times of intake as indicated. defecation per day. Provide for changes in dietary intake. BRAT diet: Banana, Rice, Apple, Tea

For baseline data For baseline data comparison

To allow for bowel reduced workload. To avoid food substances that precipitate diarrhea.

Encourage oral intake of fluids containing electrolytes. Administer medications if ordered by the Doctor.

To supplement electrolytes and fluid loss. To decrease motility and minimize fluid losses as possible.

ASSESSMENT SUBJECTIVE: Ang masyadong malaki ang tiyan ko as verbalized by the patient. OBJECTIVE: Self-negating verbalization measurement of abdomen: 34cm length 84cm width

DIAGNOSIS Situational low selfesteem r/t current situational challenge to self-worth manifested by selfnegating and low self-confident

PLANNING

INTERVENTION

RATIONALE

Within 1 hour of The nurse will: nursing intervention the Indentify basic sense of client will: self steam of client, o Acknowledge image client has of self factors that lead to possibility of Determine clients feelings of awareness of own low selfresponsibility for esteem. dealing with situation, personal growth, and so o Demonstrate fort self confidence by setting realistic Assist client to problem goals and solve situation, actively developing plan of participating action and setting goals in life to achieve desire goals situation. to achieve desire outcomes Provide feedback of client self negating remarks/behaviour, using I-messages it. Encourage involvement

In order to the patient to know what particular reasons of his low self esteem. In order the patient to be aware of the problem that brought him to low selfesteem.

EVALUATION Within an hour of nursing intervention the client will: A. Acknowledge factors that lead to possibility of feelings of low selfesteem. B. Demonstrate self confidence by setting realistic goals and actively participating in life situation. As evidenced by positive outlook from his current condition. -GOAL MET-

enhances commitment to plan optimizing outcomes

To allow the client to experience different view

the patient will be

in decisions about care when possible. Encourage use of visualization guided imaging, and relaxation to promote positive serve of self. Convey confidence in clients ability to cope with current situation.

aware in terms of his Health care. In order to the patient not to lose hope

In order to the patient to cope up from his condition.

ASSESSMENT Subjective: hindi ko alam na sakit napala ito, napansin ko lang na masyado ng lumalaki ang tiyan ko as verbalized by the patient Objective: Patients verbalization of unawareness Inadequate self awareness about his health condition

DIAGNOSIS Deficient knowledge r/t unavailability of data presented manifested by patients inadequate awareness about his present health condition.

PLANNING

INTERVENTION

RATIONALE

EVALUATION
Within an hour of nursing interventions the patient had verbalized understanding of health condition process as evidenced by participating in learning process. -GOAL MET-

Within an hour of The nurse will: nursing intervention the client will Determine clients verbalize most urgent need understanding of from clients and health condition nurses view point process as evidenced by participating in State objectives learning process clearly in learners terms Determine clients method of accessing information and include in teaching plan Begin with information the client already knows and move to what the client does not know progressing from simple to complex Provide positive reinforcement

Identifies information that can be addressed at a later time

To meet learners needs

To facilitate learnings

Limits sense of being overwhelmed

Encourages continuation of efforts

Identify motivating factors for the individual Let the patient be alert to signs and avoidance

To have interest in the learning process

In order for the patient to be aware

DISCHARGE CARE PLAN

MEDICATION Explain thoroughly to Patient MA the importance of immediate or continuous treatment of liver cirrhosis. Encourage patient MA to take his medicine/s religiously or as needed depending on the Physicians order. EXERCISE Encourage patient MA to have some form of exercise within his potential ability to minimize complications. Teach the client for a change of lifestyle. Advice patient for moderate drinking alcoholic drinks and moderate smoking and if possible step by step excluding any vices that would make the health problems be worst. TREATMENT Advice patient MA to seek for diagnostic evaluations, if ever conditions got worse. The success of treatment on convincing the patient of the needed to adverse completely to the therapeutic plan. This may include rest, lifestyle changes, adequate dietary intake and the elimination of alcohol. HYGIENE Let the Patient MA be informed the importance for extensive personal hygiene and as possible patient MA would perform extensive personal hygiene as part of his new change lifestyle. OPD CHECK-UP Instruct patient to follow indicated or schedules follow up check-up for faster recovery. DIET Encourage patient MA to consume a balance diet specifically: BRAT diet (Banana, Rice, Apple, and Tea). Sodium restriction will continue for a considerable time, if not permanently. SPIRITUAL Encourage Patient MA to maintain a good relationship with his personal God for Spiritual Graces. SOCIAL Advise Patient MA to continue his social life as long as he knows limitations especially regarding activities.