CASE

PRESENTATION

Name: Mrs. D

PATIENTS PROFILE

Age: 39 years old Gender: Female Address :Bonifacio, Makati City Date of Birth: July 3, 1972 Civil Status: Married Religion: Baptist Nationality: Filipino Occupation: Accountant Spouse: Mr. D

PATIENTs HISTORY

Date of Admission: January 16, 2012 (9:12pm) Mode of Admission:Wheelchair from ER (Accompanied by Husband) Chief Complaint: Abdominal Pain Admitting Diagnosis: Fatty Liver, Gallbladder Polyp Patient D has no history of Hypertension, DM, Asthma, or any allergic reaction to medications. She has also no history of any discussed diseases on her family.The patient was neither a smoker nor a drinker. She consumes four meals a day, with some foods high on fats.

ANATOMY and PHYSIOLOGY

Gastrointestinal System
LIVER
largest organ in the body Mainly located RUQ of the abdomen Divided into two regions:  Right lobe (larger)  Left lobe (smaller) LOBULES: functional unit Blood Supply: (1,500 ml of blood flow/minute)  Hepatic Portal Vein  Hepatic Artery Phagocytic KUPFFER CELLS

GALLBLADDER
A pear-shaped bulbous sac , located inferior surface of the liver Three portions:  Neck continuos with cystic duct  Body main portion  Fundus lower bulbous section Drained by the Cystic duct, joining the Hepatic Duct from the liver forming the COMMON BILE DUCT

y      

LIVER: Produces BILES Regulates blood glucose ( Glycogenesis/ Glycogenolysis) Synthesizes proteins and other AA Converts Ammonia to Urea for kidney elimination Stores Vitamins (ADEK) and Minerals Brakes down certain toxic substances and hormones (Kupffer cells)

GALLBLADDER:  Collects, concentrates, and stores BILE  Releases the bile into duodenum via common bile duct when fat is present.

UNKNOWN (Lifestyle, Excessive intake of fatty foods) STEATOSIS (Abnormal accumulation of lipid) Fat deposits in the liver

Inflammation of the Liver

Swelling of surrounding tissues

Vasoconstriction of blood vessels on the affected part Decreased blood supply

Damaged hepatocytes Inc. AST & ALT / SGPT & SGOT

Decreased tissue perfussion

Bile Duct obsttruction

Tissue Ischemia

Gallbladder Polyps

Activationof Nociceptors

LRUQ Pain

Somatic Pain

LABORATORY EXAMINATIONS

Blood Components ALKALINE PHOSPHATASE

Result 156

Normal Range F: 42-98 /L

Interpretation INCREASED in liver diseases (cholestasis, fatty liver, cholecystitis, cirrhosis, hepatitis, liver tumor), drug intoxication; drugs (verapamil, carbamazepine, phenytoin, erythromycin, allopurinol, ranitidine)

BLOOD UREA NITROGEN (BUN)

1.4

2.2-7.1 mmol/L

DECREASED in hepatic failure, nephrotic syndrome, cachexia (low protein and high carbohydrate diets)

CREATININE FASTING BLOOD SUGAR SERUM GLUTAMIC PYRUVIC TRANSAMINASE (SGPT)

62 5.0 301

F: 53-97 mol/L 3.9-5.8 mmol/L F: 3-31/L

NORMAL NORMAL INCREASED in acute viral hepatitis, diabetes, CHF, liver damage, bile duct obstructions, infectious mononucleosis, myopathy; hepatotoxic drug

AMYLASE SERUM GLUTAMIC OXALOACETIC TRANSMINASE (SGOT)

69 249

27-102 /L F: 2-31 /L

NORMAL INCREASED in acute viral hepatitis, biliary tract obstraction, mononucleoisis, alcoholic hepatitis and cirrhosis, liver abscess, ischemic injury to liver, myopathy

Lipid Profile HIGH DENSITY LIPOPROTEIN CHOLESTEROL (HDL) TOTAL CHOLESTEROL

Result 1.36

Normal Range Low <1.03 Medium 1.03-1.56 High >1.56

Interpretation MEDIUM / NORMAL

6.50

Desirable <5.16 HIGH Borderline High Associated with atherosclerosis, biliary 5.16-6.17 cirrhosis, high-cholesterol diet, High >6.18 hypothyroidism, myocardial infarction, nephritic syndrome, uncontrolled diabetes Optimal <2.58 Near/Low Optimal 2.58-3.34 Borderline High 3.35-4.12 High 4.13-4.89 Very High >4.90 HIGH Connected with heart diseases including atherosclerosis, heart attack, stroke, and coronary heart disease

LOW DENSITY LIPOPROTEIN CHOLESTEROL (LDL)

4.36

TRIGLYCERIDES

1.72

Normal <1.70 BORDERLINE HIGH Borderline High Slightly above normal; associated with 1.70-2.25 cirrhosis, hypothyroidism, low protein in diet High 2.26-5.63 and high carbohydrates, pancreatitis, poorly Very High >5.65 controlled diabetes, nephrotic syndrome

Serum Result Electrolytes SODIUM POTASSIUM CHLORIDE CALCIUM 141 3.9 101 1.24 138-146 mmol/L 3.6-5.0 mmol/L 96-110 mmol/L 1.15-1.29 mmol/L NORMAL NORMAL NORMAL NORMAL Normal Range Interpretation

Complete Blood Count WBC Differential Count NEUTROPHILS

Result 9.3 Result 0.62

Normal Range 5.0-10.0x10 g/L Normal Range 0.40-0.60

Interpretation NORMAL Interpretation INCREASED in infection (bacterial or early viral), acute stress, acute and chronic inflammation, tumor, drugs, DKA

LYMPHOCYTES MONOCYTES EOSINOPHILS BASOPHILS

0.26 0.08 0.02 0.02

0.20-0.40 0.02-0.08 0.01-0.03 0-0.02

NORMAL NORMAL NORMAL NORMAL

Blood Compounds HEMOGLOBIN HEMATOCRIT RBC MEAN CORPUSCULAR VOLUME (MCV) MEAN CORPUSCULAR HEMOGLOBIN (MCH) MEAN CORPUSCULAR HEMOGLOBIN CONCENTRATION (MCHC) RANDOM DISTRIBUTION WIDTH (RDW)

Result 142 0.42 4.88 87

Normal Range F: 123-152 g/L F: 0.37-0.42 F: 4.5-5.5x1012/L 88-96

Interpretation NORMAL NORMAL NORMAL NORMAL

29.1

27-33 pg

NORMAL

336

300-360 g/L

NORMAL

12.5

12.7-22.7%

DECREASED in iron deficiency anemia (blood loss, parasites, poor iron absorption), vitamin B6 anemia, rheumatoid arthritis

PLATELET MEAN PLATELET VOLUME (MPV)

327 4.38

150-450x20 g/L 4.5-7.5 fL

NORMAL DECREASED platelet production problems; thrombocytopenia, leukemia

Macroscopic COLOR TRANSPARENCY

Result Dark yellow turbid

Interpretation May indicate dehydration May be a symptom of bacterial infection; can be caused by crystallization of salts (calcium phosphate)

Chemical SPECIFIC GRAVITY pH

Result 1.010 8.5

Range 1.003-1.030 4.5-8

Interpretation NORMAL INCREASED Alkalinic; kidney failure, UTI, vomiting; in diet high in citrus, vegetables, dairy; drugs (acetazolamide, potassium citrate, sodium bicarbonate)

UROBILINOGEN

+2

0.2-1 mg/dL

INCREASED Associated with liver diseases (hepatitis, cirrhosis), increased RBC destruction (haemolytic anemia)

Chemical
NITRITE PROTEIN GLUCOSE KETONE

Result
Negative Negative Negative Negative

Chemical
BILIRUBIN LEUKOCYTES BLOOD PREGNANCY

Result
Negative Negative Negative Negative

Microscopic
RBC PUS CELLS BACTERIA EPITHELIAL CELLS MUCUS THREADS

Results
0-2 / HPF 0-2 / HPF Few +1 Few

Crystal AMORPHOUS PHOSPHATES

Result +1

Interpretation Present in an alkaline urine; can be caused by diet (vegetarian, phosphate-rich foods), or by pathological conditions (UTI, kidney failure)

Drug Name & Classifi Classification cation Generic Name: Antacid and Pantoprazole antiulcer Brand Name: Pantoloc

Adverse Effects Symptomatic Inhibits proton Frequently: treatment of pump activity headache, mild reflux by binding to diarrhea esophagitis; hydrogenRarely: long term potassium nausea, management adenosine upper and triphosphatas abdominal prevention e, located at pain, of relapse of secretory flatulence, reflux surface of skin rash, esophagitis; gastric parietal pruritus or duodenal cells, to dizziness. and gastric suppress ulcers, reflux gastric acid esophagitis; secretion. eradication of H. pylori. Action Indication

Contra indications Patients with a history of hypersensitivi ty to pantoprazole or to any constituents of the medication. It is also contraindicat ed in patients with cirrhosis of the liver and in cases of severe liver disease.

Nursing Considerations >alert: don t confuse with protonix tablet >drug can be given without regard to meals >drug shouldn t be used for maintenance therapy beyond 16 weeks. >symptomatic response to therapy doesn t preclude the presence of gastric malignancy.

Drug Name & Classification

Classifi cation

Action Prevention of nausea and vomiting associated with emetogenic cancer chemothera py; relief symptoms of acue and recurrent diabetic gastroparesi s; prophylaxis of postoperativ enausea and vomiting when nasogastric suctioning is undesirable.

Indication Stimulates motility of upper GI tract without stimulating gastric biliary, or pancreatic secretions

Adverse Effects Restlessness, drowsiness, insomnia, extrapyramid al reactions, akathisia, myoclonus

Contra indications Contraindicat ed with allergy to metocloprami de; GI hemorrhage, mechanical obstruction or perforation, epilepsy

Nursing Considerations >Monitor BP carefully during IV administration >monitor extrapyramidal reactions, and consult physician if they occur. >Keep diphenhydramine injection readily available incase of extrapyramidal reactions occur. > Do not use alcohol, sleep remedies or sedative; serious sedation may occur.

Generic Name: Antiemetic Metocloprami de Brand Name: Plasil

Drug Name & Classification

Generic Name: Ursodeoxycolic Acid Brand Name: Ursofalk

Classifi cation
Anticholelithic

Action
Indicated in the treatment of primary biliary cirrhosis (PBC) and for the dissolution of radiolucent gallstones in patients with a functioning gall bladder Gallstone formation (prophylaxis). trea tment of some chronic liver diseases, including primary biliary cirrhosis, primary sclerosing cholangitis, cystic fibrosis associated liver disease, biliary atresia, chronic hepatitis, and alcoholic cirrhosis

Indication
Anticholelithic Although the exact mechanism of ursodiol's anticholelithic action is not completely understood, it is known that when administered orally ursodiol is concentrated in bile and decreases biliary cholesterol saturation by suppressing hepatic synthesis and secretion of cholesterol, and by inhibiting its intestinal absorption.

Adverse Effects
Back pain, diarrhea, alopecia, constipation , dyspepsia, dizziness, nausea, psoriasis, vomiting

Contra indications
Acute inflammation of the gallbladder and bile ducts; obstruction of the biliary tract (common bile duct or cystic duct), inflammation disorders of the large and small intestine, pregnancy. Ursofalk should not be taken when the gallbladder cannot be visualized at x-ray, in patients with calcified gallstones, disturbed contractility of the gallbladder or frequent biliary colic.

Nursing Considerations
> Regular visits to physician to check progress; laboratory tests may be required during therapy >Avoiding aluminumcontaining antacids; may interfere with absorption of ursodiol >Notifying physician immediately if symptoms of acute cholecystitis develop >Should be taken with food

Drug Name & Classification Generic Name: Paracetamol Brand Name: Biogesic

Classifi cation Antipyretic and analgesic

Action Symptomati c relief of pain an fever

Indication Reducing fever by acting directly on the hypothalami c heatregulating center to cause vasodilation and sweating, which helps dissipate heat.

Adverse Effects hemolytic anemia, neutropenia, leucopenia, pancytopenia, Jaundice, hypoglycemia, rash

Contra indications Contraindicat ed in patients hypersensitiv ity to drug. Use cautiously in patients with long term alcohol use because therapeutic doses cause hepatotoxicit y in these patient.

Nursing Considerations >Use liquid form for children and patients who have difficulty swallowing. > In children, don t exceed five doses in 24 hours. >Advise patient that drug is only for short term use and to consult the physician if giving to children for longer than 5 days or adults for longer than 10 days. >Advise patient or caregiver that many over the counter products contain acetaminophen; be aware of this when calculating total daily dose.

Drug Name & Classification Generic Name: Atorvastatin Brand Name: Lipitor

Classifi cation

Action

Indication Inhibits enzyme that catalyzes the first step in the cholesterol synthesis pathway, resulting in a decrease in serum cholesterol, serum LDLs (associated with increased risk of CAD), and increases serum HDLs (associated with decreased risk of CAD); increases hepatic LDL recapture sites, enhances reuptake and catabolism of LDL;

Adverse Effects Headache , asthenia, Flatulence , abdominal pain, cramps, constipati on, nausea, dyspepsia, heartburn, liver failure, Sinusitis, pharyngiti s, arthralgia, myalgia

Contra indications Contraindicat ed with allergy to atorvastatin, fungal byproducts, active liver disease or unexplained and persistent elevations of transaminase levels, pregnancy, lactation. Use cautiously with impaired endocrine function.

Nursing Considerations > Withhold atorvastatin in any acute, serious condition (severe infection, hypotension, major surgery, trauma, severe metabolic or endocrine disorder, seizures) that may suggest myopathy or serve as risk factor for development of renal failure. > Ensure that patient has tried cholesterol-lowering diet regimen for 3 6 mo before beginning therapy. > Administer drug without regard to food, but at same time each day. > Consult dietitian about low-cholesterol diets. > Take this drug once a day, at about the same time each day, preferably in the evening; may be taken with food. Do not drink grapefruit juice.

Anti Adjunct to diet in hyperlipid treatment of emic elevated total cholesterol, serum triglycerides, and LDL cholesterol in patients with primary hypercholesterole mia and mixed dyslipidemia, primary dysbetalipoprotei nemia, and homozygous familial hypercholesterole mia whose response to dietary restriction of saturated fat and cholesterol

ASSESSMENT

DIAGNOSIS

PLANNING

Subjective: - Masakit ang aking tagiliran , a s verbalized by the patient. Objective: -Vital signs BP: 130/90 Temp: 36.9 PR: 90 RR: 25 -feeling of bloatedness -Pain scale of 7/10 -with facial grimace -with guarding behavior on the affected site. -verbal report of acute pain.

Acute pain related to abdominal distention as manifested by facial grimace, guarding behavior and verbal report of acute pain.

After 2 hours of nursing interventions, the client should manifest a decrease in the pain scale of 7/10 to a manageable level of 0 to 4.

INTERVENTION Independent: Assess the client s pain scale and perception Encourage verbal report during and after the nursing interventions Monitor vital signs and pain scale.

Provide a quiet, non disturbing environment with comfortable temperature Teach client divertional activities Elicit behaviours that are conditioned to produce relaxation, such as deep breathing or abdominal breathing. Bed rest in low fowler s position. Dependent: Administer analgesic as ordered by the physician.

RATIONALE Independent: To identify the intensity, onset, and duration To identify the effectiveness of the interventions Vital signs changes during onset of pain, for future comparison after interventions. Comfort and a quiet atmosphere promote a relaxed feeling -

EVALUATION

After 2 hours of nursing intervention the goals are met and the client s pain is decreased from 7/10 to 3/10.

To divert client s attention from pain Relaxations techniques help reduce skeletal muscle tension which will reduce the intensity of the pain. Reduces intraabdominal pressure Dependent: To relieve client s pain using pharmacologic intervention. Collaborative: Collaborative: Carry out doctor s order for Blood test reveals an blood test increase in WBC count. Educative: Promotes gas formation, Educative: which can increase Suggest patient limit gum gastric chewing, hard candy. distention/discomfort.

Be sure the patient understands any medication prescribed, including names of the drugs, dosage, route, action and side effects. Advocate the patient to adhere to therapeutic regimens. Encourage to follow up with his nutritionist regarding his diet. Encourage to use of stress management techniques, e.g., progressive relaxation, deep-breathing exercises to promote muscle relaxation and manage any discomfort. Encourage the patient to routinely exercise digits/joints distal to injury to enhance circulation. Advocate the patient to report any unusual/sudden pain or deep, progressive, and poorly localized pain to prevent further infection/complication.

Encourage family members to inform the patient to attend follow up appointments with his physician. Advise the patient to have adequate rest and sleep and to eat a healthy & balanced diet. Encourage patient to eat high calorie, moderate protein meal and to have supplementary feedings. Suggest small, frequent feedings and attractive meals in an aesthetically pleasing setting at meal time. Encourage and assist with gradually increasing periods of exercise. Provide emotional support to enhance coping abilities in the management of the stress of injury and pain.