A case study on cirrhosis of liver
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Apr 24, 2016
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About This Presentation
case study on liver cirrhosis
Slide Content
OObbjjeeccttiivveess ooff CCaassee ssttuuddyy
TToo ggaaiinn iinn--ddeepptthh kknnoowwlleeddggee aabboouutt tthhee ssttuuddyy ssuubbjjeecctt//ddiisseeaassee
ccoonnddiittiioonn..
TToo ggaaiinn tthhee ccoonnffiiddeennccee iinn hhaannddlliinngg ssuucchh ccaasseess iinn ffuuttuurree..
TToo ffuullffiillll tthhee ppaarrttiiaall ccoouurrssee oobbjjeeccttiivvee ooff MM..NN.. ccuurrrriiccuulluumm..
To share experience and knowledge to friends, juniors and seniors.
Rational for the selection of case
Cirrhosis is ranked as the 9
th
leading cause of death in the united state and 4
th
leading
cause of death in person between 35 and 45 years of life.
Excessive alcohol injection is the single most common cause of cirrhosis and
alcoholism is common in Nepalese society, that’s why it is the interesting case for
study so, I select this case.
A CASE STUDY ON CIRRHOSIS OF LIVER
Health History:
A: Bio-graphical Data:
Patient’s Name : - Mrs. Thumi Sara Marsagni
Age/ sex :-75 yrs/female
Marital status : - Married
Education : - Literate
Occupation : - Agriculture
Religion : - Hind
Address :- Nawalparasi, Gaidakot ,1
Ward :- Female Medical Ward
Bed No. : - 31
IP No. :- 45697
Date of admission :- 2068/07/13
Provisional Diagnosis:- Cirrhosis of Liver
Interview date :- 2068/07/14
Date of discharge :- 2068/07/18
TToo ggaaiinn iinn--ddeepptthh kknnoowwlleeddggee aabboouutt tthhee ssttuuddyy ssuubbjjeecctt//ddiisseeaassee
ccoonnddiittiioonn..
TToo ggaaiinn tthhee ccoonnffiiddeennccee iinn hhaannddlliinngg ssuucchh ccaasseess iinn ffuuttuurree..
TToo ffuullffiillll tthhee ppaarrttiiaall ccoouurrssee oobbjjeeccttiivvee ooff MM..NN.. ccuurrrriiccuulluumm..
To share experience and knowledge to friends, juniors and seniors.
Rational for the selection of case
Cirrhosis is ranked as the 9
th
leading cause of death in the united state and 4
th
leading
cause of death in person between 35 and 45 years of life.
Excessive alcohol injection is the single most common cause of cirrhosis and
alcoholism is common in Nepalese society, that’s why it is the interesting case for
study so, I select this case.
A CASE STUDY ON CIRRHOSIS OF LIVER
Health History:
A: Bio-graphical Data:
Patient’s Name : - Mrs. Thumi Sara Marsagni
Age/ sex :-75 yrs/female
Marital status : - Married
Education : - Literate
Occupation : - Agriculture
Religion : - Hind
Address :- Nawalparasi, Gaidakot ,1
Ward :- Female Medical Ward
Bed No. : - 31
IP No. :- 45697
Date of admission :- 2068/07/13
Provisional Diagnosis:- Cirrhosis of Liver
Interview date :- 2068/07/14
Date of discharge :- 2068/07/18
Final Diagnosis :- Cirrhosis of Liver
Attending physician :-
Informants Obtained From :- Patient (self) & his son
B : Chief complain
Abdominal distention since 15-16 days
Bilateral pedal swelling since 10-12 days
Moderate shortness of breathing since 5-7 days
Loss of appetite since 15-16 days
C. Present Illness/ Health Status
1. Summary of Present illness;
Mrs . Thumisara was absolutely fine before 17monts back. Gradually she
developed the problems of abdominal distension, swelling of lower legs and
mild to moderate shortness of breathing, so her family members took her in
medical shop near by her home and she was referred to hospital for further
management . at that time she attained the medical OPD and cirrhosis of
liver was diagnosed and advised to take oral medicines and stop of alcohol
. Her condition was gradually improved.
Thumisara again started to take alcohol since 6-7 months and the problem
was relapsed again and she was admitted.
2. Investigation of symptom
symptoms onset character duration Alleviating
factors
Aggravating
factor
Abdominal
distention
15-
16days
moderate _ _ While
taking more
fluids and
alcohol
Bilateral
pedal
swelling
since
10-12
days
moderate _ _ _
Attending physician :-
Informants Obtained From :- Patient (self) & his son
B : Chief complain
Abdominal distention since 15-16 days
Bilateral pedal swelling since 10-12 days
Moderate shortness of breathing since 5-7 days
Loss of appetite since 15-16 days
C. Present Illness/ Health Status
1. Summary of Present illness;
Mrs . Thumisara was absolutely fine before 17monts back. Gradually she
developed the problems of abdominal distension, swelling of lower legs and
mild to moderate shortness of breathing, so her family members took her in
medical shop near by her home and she was referred to hospital for further
management . at that time she attained the medical OPD and cirrhosis of
liver was diagnosed and advised to take oral medicines and stop of alcohol
. Her condition was gradually improved.
Thumisara again started to take alcohol since 6-7 months and the problem
was relapsed again and she was admitted.
2. Investigation of symptom
symptoms onset character duration Alleviating
factors
Aggravating
factor
Abdominal
distention
15-
16days
moderate _ _ While
taking more
fluids and
alcohol
Bilateral
pedal
swelling
since
10-12
days
moderate _ _ _
shortness
of
breathing
5-7
days
Mild to
moderate
_ Abdominal
distention
Resting in
upright
position
Loss of
appetite
since
15-16
days
moderate _ _ _
D.Past Illness:
Childhood Illness Adult Illness
2) Injuries and Accidents: My patient had no any history of external injuries and
accidents.
3) Hospitalization, Operations or Special Treatment: she had no history of
previous hospitalization , but she had treated in OPD with same problem before 17
months.
4) Allergies:-According to my patient she has not known allergies to any food,
Drugs and others
Diseases yes No Disease Yes No
Measles Hypertension
Mumps Heart disease
Whooping
cough
Tuberculosis
Polio Diabetes
Rheumatic
Fever
Filariasis
Tuberculosis Malaria
Malnutrition Cancer
operation Asthma
Others Accidents
Others
of
breathing
5-7
days
Mild to
moderate
_ Abdominal
distention
Resting in
upright
position
Loss of
appetite
since
15-16
days
moderate _ _ _
D.Past Illness:
Childhood Illness Adult Illness
2) Injuries and Accidents: My patient had no any history of external injuries and
accidents.
3) Hospitalization, Operations or Special Treatment: she had no history of
previous hospitalization , but she had treated in OPD with same problem before 17
months.
4) Allergies:-According to my patient she has not known allergies to any food,
Drugs and others
Diseases yes No Disease Yes No
Measles Hypertension
Mumps Heart disease
Whooping
cough
Tuberculosis
Polio Diabetes
Rheumatic
Fever
Filariasis
Tuberculosis Malaria
Malnutrition Cancer
operation Asthma
Others Accidents
Others
5) Medication Taken at Home :- She uses to takes some home remedy like
Juwano, ginger , besar , marcha for some common health problem.
6) Traditional Healer’s Prescription: According to my patient, sometimes she also
used to take the Traditional Healer’s prescriptions for her and her family’s health
problems.
7) Medical Practioner’s prescription:- According to my patient, she takes medical
practioner’s prescription for his health problem.
8)Self prescription: My patient use to take some common medicines like ,
paracetamol, Decold , Diagen in her family members’ prescription whenever she
has problem like headache ,fever , common cold , etc. but they doesn’t know the
drug doses, it’s side effect ,indication and contraindications etc.
Family History
1)
No. of children Age(year) Health Status
Krishna Bahadur
Marsagni
48 years Healthy
Pashupati Marsangi 46 years Healthy
Drupati Marsangi 42 years Healthy
Dol Kumari Marsangi 39 years Healthy
Bharat Marsangi 37 years Healthy
2) History of Any of the Disease below in Mother’s and Father’s Family
Disease Father’s Family Mother’s
Family
Remarks
yes No yes No
Hypertension
Diabetes
Cancer
Blood disorder
Asthma
Cardiovascular
problems
Arthritis/Gout
Juwano, ginger , besar , marcha for some common health problem.
6) Traditional Healer’s Prescription: According to my patient, sometimes she also
used to take the Traditional Healer’s prescriptions for her and her family’s health
problems.
7) Medical Practioner’s prescription:- According to my patient, she takes medical
practioner’s prescription for his health problem.
8)Self prescription: My patient use to take some common medicines like ,
paracetamol, Decold , Diagen in her family members’ prescription whenever she
has problem like headache ,fever , common cold , etc. but they doesn’t know the
drug doses, it’s side effect ,indication and contraindications etc.
Family History
1)
No. of children Age(year) Health Status
Krishna Bahadur
Marsagni
48 years Healthy
Pashupati Marsangi 46 years Healthy
Drupati Marsangi 42 years Healthy
Dol Kumari Marsangi 39 years Healthy
Bharat Marsangi 37 years Healthy
2) History of Any of the Disease below in Mother’s and Father’s Family
Disease Father’s Family Mother’s
Family
Remarks
yes No yes No
Hypertension
Diabetes
Cancer
Blood disorder
Asthma
Cardiovascular
problems
Arthritis/Gout
Tuberculosis
Other specify
FAMILY TREE
F. Psychological:
a) Client’s Reaction to illness:
Mrs . Thumisara, has normal reaction to her illness .
b) Client’s Coping Pattern:
she is using her past experiences of illness, other life experiences and support from
the family, relatives as well as health person as coping pattern.
c) Client’s Value of Health:
she thinks that health is very essential for young age but have to maintain for
lifelong as we can.
d) Client’s Perception of the Care Giver:
she thinks that all health care provider are very kind.
75
years
42
yrs
yrsyr
s
48
yrs
37
yrs
46
yrs
39
yrs
Other specify
FAMILY TREE
F. Psychological:
a) Client’s Reaction to illness:
Mrs . Thumisara, has normal reaction to her illness .
b) Client’s Coping Pattern:
she is using her past experiences of illness, other life experiences and support from
the family, relatives as well as health person as coping pattern.
c) Client’s Value of Health:
she thinks that health is very essential for young age but have to maintain for
lifelong as we can.
d) Client’s Perception of the Care Giver:
she thinks that all health care provider are very kind.
75
years
42
yrs
yrsyr
s
48
yrs
37
yrs
46
yrs
39
yrs
G. Sociological:
a) Family Relationship:
Client’s Position in the Family: she is the eldest person of the family.
Person Living With Client (Support System) : Her Family Members (sons ,daughters
granddaughter and grandsons.
Recent Family Crisis or Changes: according to informant, they have difficult in
managing the time for their sick mother because they have to go for work and
study.
B) Occupational History:
Present Job: she is very old ,so she cannot do any work.
.
c) Educational Level:
Highest Degree or Grade Attended: illiterate
Level of Learning: illiterate)
Cultural:
Ethnic Group: Magar
Client’s Beliefs about Health and Illness: Her beliefs that the illness is caused by
the unhappiness by god.
Client’s Health Practice: According to she , she don’t have any idea for good health
practice
Sources of Care(Modern /traditional): According to her and her informant ,
sometimes they goes to traditional healer , sometimes they goes to local medical
shop and health post as well as Hospital for health seeking.
e) Leisure Time Activities: she spends her time with her grandsons and grand-
daughters
f) Chemical Use (type, frequency, problems related to use)
Cigarettes: smoker. She takes 3-4 sticks /day
Substances (e.g. Hashish, bidi, etc):- Non –user
Alcohol: she takes alcohol every day about 800-1000ml.
H. Environmental History:
a) Family Relationship:
Client’s Position in the Family: she is the eldest person of the family.
Person Living With Client (Support System) : Her Family Members (sons ,daughters
granddaughter and grandsons.
Recent Family Crisis or Changes: according to informant, they have difficult in
managing the time for their sick mother because they have to go for work and
study.
B) Occupational History:
Present Job: she is very old ,so she cannot do any work.
.
c) Educational Level:
Highest Degree or Grade Attended: illiterate
Level of Learning: illiterate)
Cultural:
Ethnic Group: Magar
Client’s Beliefs about Health and Illness: Her beliefs that the illness is caused by
the unhappiness by god.
Client’s Health Practice: According to she , she don’t have any idea for good health
practice
Sources of Care(Modern /traditional): According to her and her informant ,
sometimes they goes to traditional healer , sometimes they goes to local medical
shop and health post as well as Hospital for health seeking.
e) Leisure Time Activities: she spends her time with her grandsons and grand-
daughters
f) Chemical Use (type, frequency, problems related to use)
Cigarettes: smoker. She takes 3-4 sticks /day
Substances (e.g. Hashish, bidi, etc):- Non –user
Alcohol: she takes alcohol every day about 800-1000ml.
H. Environmental History:
a) Type of Drainage System: Open
b) Types of Toilet Used: Water seal
c) Sources of drinking Water: Tap water (unboiled water)
) Kitchen Style: Separate kitchen
e) Types of Fuel Used in Cooking: Fire-Wood
I. Significant Development Task
a) Past if Relevant…………………………………………………………
b)Current in Terms Of Appropriate Task For Age…………..
………………………………………………………………………………….
Developmental tasks of older adulthood
S.N. According to
book
According to patient
1 Adjusting to
decreasing health
and physical
strength
My patient is adjusting her
decreasing health and physical
strength as she is depending on
stick while walking .
As she is older she cannot do
household work so she is
depending to her family members
for her activities of daily living
She is accepting her decrease
health and physical strength as
normal phenomena.
2 Adjusting to
reduced or fixed
income
My patient has no fixed income so
she is economically fully depending
to her family members .
3 Adjusting to death
of spouse
Mrs. Thumisara has already lost her
husband for 10 years so she is
adjusting to death of spouse
4 Accepting oneself
as an aging person
Mrs. Thumisara has full awareness
that she is very old and she accepts
oneself as an aging person so she
b) Types of Toilet Used: Water seal
c) Sources of drinking Water: Tap water (unboiled water)
) Kitchen Style: Separate kitchen
e) Types of Fuel Used in Cooking: Fire-Wood
I. Significant Development Task
a) Past if Relevant…………………………………………………………
b)Current in Terms Of Appropriate Task For Age…………..
………………………………………………………………………………….
Developmental tasks of older adulthood
S.N. According to
book
According to patient
1 Adjusting to
decreasing health
and physical
strength
My patient is adjusting her
decreasing health and physical
strength as she is depending on
stick while walking .
As she is older she cannot do
household work so she is
depending to her family members
for her activities of daily living
She is accepting her decrease
health and physical strength as
normal phenomena.
2 Adjusting to
reduced or fixed
income
My patient has no fixed income so
she is economically fully depending
to her family members .
3 Adjusting to death
of spouse
Mrs. Thumisara has already lost her
husband for 10 years so she is
adjusting to death of spouse
4 Accepting oneself
as an aging person
Mrs. Thumisara has full awareness
that she is very old and she accepts
oneself as an aging person so she
handed over her kingship to her son
and daughter- in law
5 Maintaining
satisfactory living
arrangements
Mrs. Thumisara has not maintained
her own satisfactory living
arrangement because she is non job
holder women however she is
satisfied whatever she has now.
6
Redefining
relationships with
adult children.
My patient redefining relationship
with adult children as she is still
honorable in her family as a head of
family so she gives her valuable
advice and suggestion to her family
as needed.
7 Finding meaning in
life.
My patient is accepting the god’s
natural phenomena towards the
living creature and realizing that she
fulfilled her female role sincerely.
and daughter- in law
5 Maintaining
satisfactory living
arrangements
Mrs. Thumisara has not maintained
her own satisfactory living
arrangement because she is non job
holder women however she is
satisfied whatever she has now.
6
Redefining
relationships with
adult children.
My patient redefining relationship
with adult children as she is still
honorable in her family as a head of
family so she gives her valuable
advice and suggestion to her family
as needed.
7 Finding meaning in
life.
My patient is accepting the god’s
natural phenomena towards the
living creature and realizing that she
fulfilled her female role sincerely.
Physical Examination
S.N Health History (Subjective
Data)
Ye
s
No Physical Examination
(objective Data)
1 General
Cognation(Limitation/Restricti
on)
Sensation(Limitation/Restricti
on)
Communication(Limitation/Re
striction
General
Gait: Imbalanced
Facial Expression (grimacing): undifferentiated
Level of consciousness: Conscious
Orientation to time ,place and person: fully
oriented
Measurements
Height: 4feet 6 inch
Weight :37 kg
Temperature : 98°C
Pulse: 90 b/min
Respiration :20 /min
Blood pressure : 110/60 mm of hg
2 Problem related to Head and
face
Headache
Injury
Puffiness of face
Hair :black and grey in colour
Scalp: dirty, dandruff present, no injury, lumps
and other lesions present
Skull: normal in shape
Face: uniform movement of side of face , slight
edema ,no masses
Sinuses : No swelling , tenderness and
depression
S.N Health History (Subjective
Data)
Ye
s
No Physical Examination
(objective Data)
1 General
Cognation(Limitation/Restricti
on)
Sensation(Limitation/Restricti
on)
Communication(Limitation/Re
striction
General
Gait: Imbalanced
Facial Expression (grimacing): undifferentiated
Level of consciousness: Conscious
Orientation to time ,place and person: fully
oriented
Measurements
Height: 4feet 6 inch
Weight :37 kg
Temperature : 98°C
Pulse: 90 b/min
Respiration :20 /min
Blood pressure : 110/60 mm of hg
2 Problem related to Head and
face
Headache
Injury
Puffiness of face
Hair :black and grey in colour
Scalp: dirty, dandruff present, no injury, lumps
and other lesions present
Skull: normal in shape
Face: uniform movement of side of face , slight
edema ,no masses
Sinuses : No swelling , tenderness and
depression
3 Problem Related to Eye/
Vision
Pain
Swelling
Discharge
Excessive tears
Difficulty Seeing at Night
Any other
problems……………………
Condition of Eyelids: No swelling, redness
,lesions
Condition of Conjunctiva: pale palpebral
conjunctivas, Condition of cornea: transparent
Colour of Sclera: yellow sclera
Pupil Size Symmetry: uniform in size and shape
Reaction to light : reactive to light
Discharge from eyes : slightly white sticky
discharge
Visual Acuity: Sub- Normal
Eye Glasses : Not used
4 Problem Related to Ear:
Pain
Tinnitus
Vertigo
Dizziness
Others …………………..
Condition of External Ear:
Normally Located external Ear
Drainage from Ear: No discharge of pus , blood
,slightly wax present
Lumps or Lesions: Not found
Ear Drum:
Hearing Aid: Not used
Rinne Test: AC>BC
Weber Test: AC>BC
5 Problems Related to Nose
Injury
Bleeding /Discharge
Blockage
Location : centrally located
Nasal Deviation : Not found
Bleeding: No
Patency of the Nostrils: patented
Any Discharge: Not found
Smell: No problem in smelling
Condition of Nasal mucosa:
Pale in colour
Flaring Nostrils: Not presented.
Inflammation: Not found.
Nasal Polyps: Not found
Vision
Pain
Swelling
Discharge
Excessive tears
Difficulty Seeing at Night
Any other
problems……………………
Condition of Eyelids: No swelling, redness
,lesions
Condition of Conjunctiva: pale palpebral
conjunctivas, Condition of cornea: transparent
Colour of Sclera: yellow sclera
Pupil Size Symmetry: uniform in size and shape
Reaction to light : reactive to light
Discharge from eyes : slightly white sticky
discharge
Visual Acuity: Sub- Normal
Eye Glasses : Not used
4 Problem Related to Ear:
Pain
Tinnitus
Vertigo
Dizziness
Others …………………..
Condition of External Ear:
Normally Located external Ear
Drainage from Ear: No discharge of pus , blood
,slightly wax present
Lumps or Lesions: Not found
Ear Drum:
Hearing Aid: Not used
Rinne Test: AC>BC
Weber Test: AC>BC
5 Problems Related to Nose
Injury
Bleeding /Discharge
Blockage
Location : centrally located
Nasal Deviation : Not found
Bleeding: No
Patency of the Nostrils: patented
Any Discharge: Not found
Smell: No problem in smelling
Condition of Nasal mucosa:
Pale in colour
Flaring Nostrils: Not presented.
Inflammation: Not found.
Nasal Polyps: Not found
6 Problems Related to Mouth
Sore on Lips
Sore on Tongue
Gum Bleeding
Missing Teeth/ Dentures
Change in Taste
Toothache
Lips: Dry
Oral Cavity: Pale mucous membrane of oral
cavity
Teeth: Missing all teeth
Tongue: slightly dry and coated tongue
Vocal cord, Uvula and Tonsils: Not enlarged and
inflamed.
7 Problems Related to Speech
Loss of Consciousness
Loss of Memory
Convulsion
Speech Disorders: Not presented.
8 Throat and Neck
Difficulty n Swallowing
Problems in Tonsil
Neck Rigidity
Location : centrally located, no tilting of head
Movement : Full and smooth range of
movement, no stiffness or tenderness
Jugular Vein : Not enlarged
Condition of Thyroid: No enlargement of
thyroid gland
Problem Related to
Respiration :
Dyspnoea
Cough
Hoarseness of Voice
Cyanosis
Others………………………………..
Respiratory Rat:20 b/min
Depth of respiration: Normal depth
Quality of Respiration : dyspnoea in lying
position
Chest Inspection
- lateral diameter is wider than anterior
posterior diameter
- sternum is located at the midline
- Even expansion of the chest during
breathing
No intercostals retraction
• Slight cough , but no productive
sputum.
Chest Palpation
Sore on Lips
Sore on Tongue
Gum Bleeding
Missing Teeth/ Dentures
Change in Taste
Toothache
Lips: Dry
Oral Cavity: Pale mucous membrane of oral
cavity
Teeth: Missing all teeth
Tongue: slightly dry and coated tongue
Vocal cord, Uvula and Tonsils: Not enlarged and
inflamed.
7 Problems Related to Speech
Loss of Consciousness
Loss of Memory
Convulsion
Speech Disorders: Not presented.
8 Throat and Neck
Difficulty n Swallowing
Problems in Tonsil
Neck Rigidity
Location : centrally located, no tilting of head
Movement : Full and smooth range of
movement, no stiffness or tenderness
Jugular Vein : Not enlarged
Condition of Thyroid: No enlargement of
thyroid gland
Problem Related to
Respiration :
Dyspnoea
Cough
Hoarseness of Voice
Cyanosis
Others………………………………..
Respiratory Rat:20 b/min
Depth of respiration: Normal depth
Quality of Respiration : dyspnoea in lying
position
Chest Inspection
- lateral diameter is wider than anterior
posterior diameter
- sternum is located at the midline
- Even expansion of the chest during
breathing
No intercostals retraction
• Slight cough , but no productive
sputum.
Chest Palpation
10
11
Heart and Circulation :
Chest pain
Numbness
Palpitation
Fever , chills
Bleeding tendencies
Others
:……………………………………………
……………………………………………
Nutrition / Hydration:
Anorexia
Nausea/ Vomiting
Unusual thirst or hunger
Diaphoresis
Non Vegetarian
Special Diet
Food Dislikes
Ability to Chew or swallow
- No tenderness, lump or depression along
the ribs.
Percussion
- Deep resonant sound heard all over the
lungs.
Auscultation
- Breath sounds are heard in all areas of the
lungs.
- Inspiration longer than expiration
- No , rhonchi, wheezing sound was
presented
Pulse Rate: Radical: 88b/min Apical: 88
b/min
Character of Pulse: Normal
Blood Pressure: Right110/60mm of hg
Left: 100/60 mm of hg
Peripheral Pulse: All present
Capillary Refill: 1 second
Edema ( e.g. puffy eye) : present
Varicosities: Absent
Visible External Jugular veins : Absent
Systolic or Diastolic Murmur : Absent
Body Build: Average
Body weight : 37 kg
Skin Turgor/ Elasticity : Normal
Condition of Buccal mucosa : intact
11
Heart and Circulation :
Chest pain
Numbness
Palpitation
Fever , chills
Bleeding tendencies
Others
:……………………………………………
……………………………………………
Nutrition / Hydration:
Anorexia
Nausea/ Vomiting
Unusual thirst or hunger
Diaphoresis
Non Vegetarian
Special Diet
Food Dislikes
Ability to Chew or swallow
- No tenderness, lump or depression along
the ribs.
Percussion
- Deep resonant sound heard all over the
lungs.
Auscultation
- Breath sounds are heard in all areas of the
lungs.
- Inspiration longer than expiration
- No , rhonchi, wheezing sound was
presented
Pulse Rate: Radical: 88b/min Apical: 88
b/min
Character of Pulse: Normal
Blood Pressure: Right110/60mm of hg
Left: 100/60 mm of hg
Peripheral Pulse: All present
Capillary Refill: 1 second
Edema ( e.g. puffy eye) : present
Varicosities: Absent
Visible External Jugular veins : Absent
Systolic or Diastolic Murmur : Absent
Body Build: Average
Body weight : 37 kg
Skin Turgor/ Elasticity : Normal
Condition of Buccal mucosa : intact
12
13
Resent change in Weight
Elimination and
reproduction:
Pain in Urination
Change in urine colour
Urinary Retention
Frequency of Urination
Incontinence of Urine
Constipation
Diarrhea
Passing worms, Mucous
Elimination and
Reproduction:
Appearance of Stool
Bleeding from Rectum
Flatulence
Heart Burn
Abdominal Pain
Discharge from Genitalia
Pain or Swelling of scrotum
Any Unexpected vaginal
bleeding
Any menstrual Disorder
Uterine prolapsed
Knowledge of family planning
method
Family Planning Device Used
Appearance of Urine : yellowish (concentrated)
Appearance of Stool: Normal
Any Enlargement of Liver, spleen: moderately
enlarged liver found.
Any Masses in Abdomen: Not Found
Any tenderness in Above Ares: Tenderness in Rt.
Hypocardium
Size and shape of abdomen: distended
abdomen
Shifting dullness: present
Distended abdominal veins : slightly
Fluid thrill: present
Abdominal girth: 33 inch
Enlarges Inguinal and femoral Nodes: Not found
Bowel sounds: Present
Lesion or tumors of Rectal Area: Not found
Abnormalities of Genito-Urinary Area: Not
found
Female- Rectocele and Cystocele: not present
Uterine prolapsed : not present
Discharge : Not present
Other………………………
………………….
13
Resent change in Weight
Elimination and
reproduction:
Pain in Urination
Change in urine colour
Urinary Retention
Frequency of Urination
Incontinence of Urine
Constipation
Diarrhea
Passing worms, Mucous
Elimination and
Reproduction:
Appearance of Stool
Bleeding from Rectum
Flatulence
Heart Burn
Abdominal Pain
Discharge from Genitalia
Pain or Swelling of scrotum
Any Unexpected vaginal
bleeding
Any menstrual Disorder
Uterine prolapsed
Knowledge of family planning
method
Family Planning Device Used
Appearance of Urine : yellowish (concentrated)
Appearance of Stool: Normal
Any Enlargement of Liver, spleen: moderately
enlarged liver found.
Any Masses in Abdomen: Not Found
Any tenderness in Above Ares: Tenderness in Rt.
Hypocardium
Size and shape of abdomen: distended
abdomen
Shifting dullness: present
Distended abdominal veins : slightly
Fluid thrill: present
Abdominal girth: 33 inch
Enlarges Inguinal and femoral Nodes: Not found
Bowel sounds: Present
Lesion or tumors of Rectal Area: Not found
Abnormalities of Genito-Urinary Area: Not
found
Female- Rectocele and Cystocele: not present
Uterine prolapsed : not present
Discharge : Not present
Other………………………
………………….
14
15
Bowel Habits:
Regular/ Irregular
Pap Smear Test Done
Mobility :
Difficulty with Ambulation
Muscle cramping or
Weakness
Muscle Pain
Back Pain
Joint Pain or Swelling
Limited Joint Movement
Ability to Do ADLS
Comfort ,Sleep and Rest:
Pain
Regular Sleep Pattern
Integumentary Hygiene :
Non –healing sores
Change in Mole Colour
Nail Changes
Itching Of Skin Sensation
Regular bathing Habit
Motor Strength and Mobility: slight reduced
Enlargement and Stiffness of Joints: Not present
Contractures: slightly Present( knee joint)
Spinal Deformity: Not Present
Range of motion Exercise: Cannot move in full
Range Of Motion
CANE: use of stick Crutches : Not used
Walker : Not used Prosthesis : Not Used
Location Of Pain : Rt. Hypochondrium
tenderness
Discomfort due to abdominal distention
Sleep disturb at night
Colour of skin, Texture, Turgor : Normal
Pigmentation, Lesion, Tumors: Not found
Skin Inflammation : Not present
Edema: present (lower legs and abdomen)
Rashes : Not present
Abnormal Nail Conditions: Not present
Distribution and Texture of Hair : equally
distributed of scalp hair, no,any abnormally
distribution in body hair , the texture of hair is
soft
Touch Sensation: Normally Presented all over
the body
Enlarged lymph Glands and nodes: Not found
15
Bowel Habits:
Regular/ Irregular
Pap Smear Test Done
Mobility :
Difficulty with Ambulation
Muscle cramping or
Weakness
Muscle Pain
Back Pain
Joint Pain or Swelling
Limited Joint Movement
Ability to Do ADLS
Comfort ,Sleep and Rest:
Pain
Regular Sleep Pattern
Integumentary Hygiene :
Non –healing sores
Change in Mole Colour
Nail Changes
Itching Of Skin Sensation
Regular bathing Habit
Motor Strength and Mobility: slight reduced
Enlargement and Stiffness of Joints: Not present
Contractures: slightly Present( knee joint)
Spinal Deformity: Not Present
Range of motion Exercise: Cannot move in full
Range Of Motion
CANE: use of stick Crutches : Not used
Walker : Not used Prosthesis : Not Used
Location Of Pain : Rt. Hypochondrium
tenderness
Discomfort due to abdominal distention
Sleep disturb at night
Colour of skin, Texture, Turgor : Normal
Pigmentation, Lesion, Tumors: Not found
Skin Inflammation : Not present
Edema: present (lower legs and abdomen)
Rashes : Not present
Abnormal Nail Conditions: Not present
Distribution and Texture of Hair : equally
distributed of scalp hair, no,any abnormally
distribution in body hair , the texture of hair is
soft
Touch Sensation: Normally Presented all over
the body
Enlarged lymph Glands and nodes: Not found
16
Reflexes
Biceps Reflex: present
Brachilo radialis: present
Triceps Reflex: present
Patellar Reflex : present
Achilles Reflex: present
Babinski Reflex : present( negative)
Kerning’s sign : Absent
UNIT II - INTRODUCTION TO DISEASE
Cirrhosis of liver
Introduction
• The term cirrhosis was first used by Rene Laennec (1781-1826) to describe
the abnormal liver color of individuals with alcohol induced liver disease.
• Derived from Greek word Kirrhos means Yellowish – brown color.
Definition:
• Cirrhosis is a chronic progressive disease of the liver characterized by
extensive degeneration and destruction of the liver parenchymal cells.
Reflexes
Biceps Reflex: present
Brachilo radialis: present
Triceps Reflex: present
Patellar Reflex : present
Achilles Reflex: present
Babinski Reflex : present( negative)
Kerning’s sign : Absent
UNIT II - INTRODUCTION TO DISEASE
Cirrhosis of liver
Introduction
• The term cirrhosis was first used by Rene Laennec (1781-1826) to describe
the abnormal liver color of individuals with alcohol induced liver disease.
• Derived from Greek word Kirrhos means Yellowish – brown color.
Definition:
• Cirrhosis is a chronic progressive disease of the liver characterized by
extensive degeneration and destruction of the liver parenchymal cells.
• Cirrhosis is a chronic disease characterized by replacement of normal liver
tissue with diffuse fibrosis that disrupts the structure and function of the
liver.
• The liver cells attempt to regenerate, but the regenerative process is
disorganized, resulting in abnormal blood vessels and bile duct
architecture.
• The liver slowly deteriorates and malfunctions due to chronic injury. Scar
tissue replaces healthy liver tissue, partially blocking the flow of blood
through the liver.
Scarring also impairs the liver's ability to:
• control infections
• remove bacteria and toxins from the blood
• process nutrients, hormones, and drugs
• make proteins that regulate blood clotting
• produce bile to help absorb fats—including cholesterol—and fat-soluble
vitamins
Incidence:
• It is the twelfth leading cause of death, 27,000 deaths each year and
affects men slightly more than women.
• It is the 10
th
leading cause of death in the US, with mortality rate of 9.2
deaths per 100,000 populations.
• Of those deaths, 45% were alcohol related. Men are more likely than
women to have alcoholic cirrhosis.
tissue with diffuse fibrosis that disrupts the structure and function of the
liver.
• The liver cells attempt to regenerate, but the regenerative process is
disorganized, resulting in abnormal blood vessels and bile duct
architecture.
• The liver slowly deteriorates and malfunctions due to chronic injury. Scar
tissue replaces healthy liver tissue, partially blocking the flow of blood
through the liver.
Scarring also impairs the liver's ability to:
• control infections
• remove bacteria and toxins from the blood
• process nutrients, hormones, and drugs
• make proteins that regulate blood clotting
• produce bile to help absorb fats—including cholesterol—and fat-soluble
vitamins
Incidence:
• It is the twelfth leading cause of death, 27,000 deaths each year and
affects men slightly more than women.
• It is the 10
th
leading cause of death in the US, with mortality rate of 9.2
deaths per 100,000 populations.
• Of those deaths, 45% were alcohol related. Men are more likely than
women to have alcoholic cirrhosis.
• Worldwide, post necrotic cirrhosis is the most common in women.
Mortality is higher from all types of cirrhosis in men and non whites.
CAUSES OF CIRRHOSIS
Alcohol
Chronic viral hepatitis (B or C) Non-alcoholic fatty liver disease
Immune
o Primary sclerosing cholangitis
o Autoimmune liver disease
Biliary
o Primary biliary cirrhosis
o Cystic fibrosis
Genetic
o Haemochromatosis
o α1-antitrypsin deficiency
o Wilson's disease
Cryptogenic (unknown)
Etiology:
Alcohol.
• Heavy alcohol for several years can cause chronic injury to the liver and
damages.
• For women, consuming two to three drinks—including beer and wine per
day and for men, three to four drinks per day, can lead to liver damage and
cirrhosis.
• A common problem in alcoholic is protein malnutrition.
Obesity:
WHO ,2008, estimated that more than 200 million men and close to 300
million women were obese, obesity is a common cause of chronic liver
disease , 17% of liver cirrhosis is attributable to excess body weight.
Chronic hepatitis C.
Mortality is higher from all types of cirrhosis in men and non whites.
CAUSES OF CIRRHOSIS
Alcohol
Chronic viral hepatitis (B or C) Non-alcoholic fatty liver disease
Immune
o Primary sclerosing cholangitis
o Autoimmune liver disease
Biliary
o Primary biliary cirrhosis
o Cystic fibrosis
Genetic
o Haemochromatosis
o α1-antitrypsin deficiency
o Wilson's disease
Cryptogenic (unknown)
Etiology:
Alcohol.
• Heavy alcohol for several years can cause chronic injury to the liver and
damages.
• For women, consuming two to three drinks—including beer and wine per
day and for men, three to four drinks per day, can lead to liver damage and
cirrhosis.
• A common problem in alcoholic is protein malnutrition.
Obesity:
WHO ,2008, estimated that more than 200 million men and close to 300
million women were obese, obesity is a common cause of chronic liver
disease , 17% of liver cirrhosis is attributable to excess body weight.
Chronic hepatitis C.
Chronic hepatitis C causes inflammation and damage to the liver over time
that can lead to cirrhosis and approximately 20% patient will develop
cirrhosis.
Chronic hepatitis B and D.
• Hepatitis B and D is virus that infects the liver and can lead to cirrhosis,
but it occurs only in people who already have hepatitis B. approximate
10%- 20% will develop cirrhosis.
Nonalcoholic fatty liver disease (NAFLD).
• This is associated with obesity, diabetes, protein malnutrition, coronary
artery disease, and corticosteroid medications.
• Autoimmune hepatitis. It is caused by the body's immune system attacking
liver cells and causing inflammation, damage, and eventually cirrhosis.
Genetic factors –
About 70 percent of those with autoimmune hepatitis are female.
Diseases that damage or destroy bile ducts.
• Several different diseases (cholangitis) can damage or destroy the ducts that
carry bile from the liver, causing bile to back up in the liver and leading to
cirrhosis.
Inherited diseases.
• Cystic fibrosis, alpha-1 antitrypsin deficiency, hemochromatosis, Wilson
disease, galactosemia, and glycogen storage diseases are inherited diseases
that interfere the liver function properly, Cirrhosis can result.
Drugs, toxins, and infections.
• Drug reactions( Acetaminophen, isonazide, methotrexate) prolonged
exposure to toxic chemicals, parasitic infections, and repeated bouts of heart
failure with liver congestion.
Types of cirrhosis :
that can lead to cirrhosis and approximately 20% patient will develop
cirrhosis.
Chronic hepatitis B and D.
• Hepatitis B and D is virus that infects the liver and can lead to cirrhosis,
but it occurs only in people who already have hepatitis B. approximate
10%- 20% will develop cirrhosis.
Nonalcoholic fatty liver disease (NAFLD).
• This is associated with obesity, diabetes, protein malnutrition, coronary
artery disease, and corticosteroid medications.
• Autoimmune hepatitis. It is caused by the body's immune system attacking
liver cells and causing inflammation, damage, and eventually cirrhosis.
Genetic factors –
About 70 percent of those with autoimmune hepatitis are female.
Diseases that damage or destroy bile ducts.
• Several different diseases (cholangitis) can damage or destroy the ducts that
carry bile from the liver, causing bile to back up in the liver and leading to
cirrhosis.
Inherited diseases.
• Cystic fibrosis, alpha-1 antitrypsin deficiency, hemochromatosis, Wilson
disease, galactosemia, and glycogen storage diseases are inherited diseases
that interfere the liver function properly, Cirrhosis can result.
Drugs, toxins, and infections.
• Drug reactions( Acetaminophen, isonazide, methotrexate) prolonged
exposure to toxic chemicals, parasitic infections, and repeated bouts of heart
failure with liver congestion.
Types of cirrhosis :
Alcoholic (historically called Laennec’s cirrhosis) cirrhosis:
• Also called micro nodular or portal cirrhosis and usually associated with
alcohol abuse.
• The first change in the liver from excessive intake is an accumulation of fat
in the liver cells; uncomplicated fatty changes in the liver are potentially
reversible if the person stops drinking alcohol.
If the alcohol abuse continues, widespread scar formation occurs
throughout the liver.
Post necrotic cirrhosis( macro nodular):
• Most common worldwide, massive loss of liver cells with irregular patterns
of regenerating cells due to complication of viral, toxic or idiopathic
(autoimmune) hepatitis.
Billiary cirrhosis: is associated with chronic billiary obstruction and
infection. There is diffuse fibrosis of the liver with jaundice.
Cardiac cirrhosis: chronic liver disease results from long-standing, severe
right side heart failure with corpulmonale, constrictive pericarditis, and
tricuspid insufficiency.
Pathophysiology :
Liver insult, alcohol ingestion, viral hepatitis, exposure to toxin
Hepatocyte damage
Liver inflammation - ↑WBCs, nausea, vomiting, pain , fever, anorexia,
fatigue
Alteration in blood and lymph flow
• Liver necrosis →liver fibrosis and scarring → portal hypertension
- ascities, edema,
• Also called micro nodular or portal cirrhosis and usually associated with
alcohol abuse.
• The first change in the liver from excessive intake is an accumulation of fat
in the liver cells; uncomplicated fatty changes in the liver are potentially
reversible if the person stops drinking alcohol.
If the alcohol abuse continues, widespread scar formation occurs
throughout the liver.
Post necrotic cirrhosis( macro nodular):
• Most common worldwide, massive loss of liver cells with irregular patterns
of regenerating cells due to complication of viral, toxic or idiopathic
(autoimmune) hepatitis.
Billiary cirrhosis: is associated with chronic billiary obstruction and
infection. There is diffuse fibrosis of the liver with jaundice.
Cardiac cirrhosis: chronic liver disease results from long-standing, severe
right side heart failure with corpulmonale, constrictive pericarditis, and
tricuspid insufficiency.
Pathophysiology :
Liver insult, alcohol ingestion, viral hepatitis, exposure to toxin
Hepatocyte damage
Liver inflammation - ↑WBCs, nausea, vomiting, pain , fever, anorexia,
fatigue
Alteration in blood and lymph flow
• Liver necrosis →liver fibrosis and scarring → portal hypertension
- ascities, edema,
- spleenomegaly(Anemia,
thrombocytopenia, leucopenia)
- Varices (esophageal varices, hemorrhoids.)
↓ billirubin metabolism – hyperbilirubinemia, jaundice
• ↓ bile in gastrointestinal tract – light colored stool
• ↑ urobilinogen – Dark Urine
• ↓ vit K absorption- bleeding tendency
• ↓ metabolism of protein, carbohydrate, fats→ hypoglycemia,
• ↓ plasma protein- ascites and edema
↓androgen and estrogen detoxification(↓ hormone metabolism)- ↑ estrogen
and androgens hormone – Gynecomastia, loss of body hair, menstrual
dysfunction, spider angioma, palmer erythema, testicular atrophy
• ↓ ADH and aldesterone detoxification so ↑ ADH levels - edema
• Biochemical alteration - ↑ AST, ALT levels, ↑ bilirubin, low serum albumin,
prolong prothombin time, elevated alkaline phosphatase.
• Liver failure
• Hepatic encephalopathy
• Hepatic coma
• Death
Clinical manifestations:
Early manifestations –
No symptoms in the early stages of the disease.
GI disturbances are more common , anorexia, dyspepsia, flatulence,
weakness, fatigue, nausea, vomiting, weight loss, abdominal pain and
bloating, and change in bowel habit ( diarrhea, constipation).
Abdominal pain, dull and heavy feeling in right upper quadrant or
epigastric due to swelling and stretching of the liver capsule, spasm of
biliary duct.
Fever, lassitude, weight loss, enlargement of liver and spleen.
thrombocytopenia, leucopenia)
- Varices (esophageal varices, hemorrhoids.)
↓ billirubin metabolism – hyperbilirubinemia, jaundice
• ↓ bile in gastrointestinal tract – light colored stool
• ↑ urobilinogen – Dark Urine
• ↓ vit K absorption- bleeding tendency
• ↓ metabolism of protein, carbohydrate, fats→ hypoglycemia,
• ↓ plasma protein- ascites and edema
↓androgen and estrogen detoxification(↓ hormone metabolism)- ↑ estrogen
and androgens hormone – Gynecomastia, loss of body hair, menstrual
dysfunction, spider angioma, palmer erythema, testicular atrophy
• ↓ ADH and aldesterone detoxification so ↑ ADH levels - edema
• Biochemical alteration - ↑ AST, ALT levels, ↑ bilirubin, low serum albumin,
prolong prothombin time, elevated alkaline phosphatase.
• Liver failure
• Hepatic encephalopathy
• Hepatic coma
• Death
Clinical manifestations:
Early manifestations –
No symptoms in the early stages of the disease.
GI disturbances are more common , anorexia, dyspepsia, flatulence,
weakness, fatigue, nausea, vomiting, weight loss, abdominal pain and
bloating, and change in bowel habit ( diarrhea, constipation).
Abdominal pain, dull and heavy feeling in right upper quadrant or
epigastric due to swelling and stretching of the liver capsule, spasm of
biliary duct.
Fever, lassitude, weight loss, enlargement of liver and spleen.
Later manifestations:
May be severe and result from liver failure and portal hypertension.
Jaundice, peripheral edema and ascities develop gradually.
Other late symptoms include skin lesion, hematological disorders, endocrine
disturbances, and peripheral neuropathy.
In the advanced stage the liver becomes small and nodular.
Jaundice:
It results from the functional derangement of liver cells and compression of
bile duct by connective tissue overgrowth.
Jaundice occurs as a result of decreased ability to conjugate and excrete
bilirubin.
If obstruction of the biliary tract occurs, obstructive jaundice may also
occur and usually accompanied by pruritus.
Skin lesion:
Spider angioma ( telangiectasia or spidernavi) are small dilated blood
vessels with a bright red center point and spider like branches occurs in
nose, cheeks, upper trunk, neck and shoulders.
Palmer erythema, a red area that blanches with pressure, is located on the
palm of the hand.
Both lesions are due to increase estrogen in blood as a result of the damaged
liver’s inability to metabolized steroid hormone.
Hematologic problem:
Thrombocytopenia, leucopenia, anemia, due to spleenomegaly (back flow of
blood from portal vein into the spleen.)
Anemia due to inadequate RBC production and survival, and due to poor
diet, poor absorption and bleeding from varices.
Coagulation problems result from the liver’s inability to produce
prothrombin and blood clotting and manifested by hemorrhagic phenomena
or bleeding tendencies e.g. epistaxis, purpura, gingival bleeding, heavy
menstrual flow.
Endocrine problem:
May be severe and result from liver failure and portal hypertension.
Jaundice, peripheral edema and ascities develop gradually.
Other late symptoms include skin lesion, hematological disorders, endocrine
disturbances, and peripheral neuropathy.
In the advanced stage the liver becomes small and nodular.
Jaundice:
It results from the functional derangement of liver cells and compression of
bile duct by connective tissue overgrowth.
Jaundice occurs as a result of decreased ability to conjugate and excrete
bilirubin.
If obstruction of the biliary tract occurs, obstructive jaundice may also
occur and usually accompanied by pruritus.
Skin lesion:
Spider angioma ( telangiectasia or spidernavi) are small dilated blood
vessels with a bright red center point and spider like branches occurs in
nose, cheeks, upper trunk, neck and shoulders.
Palmer erythema, a red area that blanches with pressure, is located on the
palm of the hand.
Both lesions are due to increase estrogen in blood as a result of the damaged
liver’s inability to metabolized steroid hormone.
Hematologic problem:
Thrombocytopenia, leucopenia, anemia, due to spleenomegaly (back flow of
blood from portal vein into the spleen.)
Anemia due to inadequate RBC production and survival, and due to poor
diet, poor absorption and bleeding from varices.
Coagulation problems result from the liver’s inability to produce
prothrombin and blood clotting and manifested by hemorrhagic phenomena
or bleeding tendencies e.g. epistaxis, purpura, gingival bleeding, heavy
menstrual flow.
Endocrine problem:
In men, Gynecomastia, loss of axillary and pubic hair, testicular atrophy
and impotence with loss of libido due to increased estrogen level.
In younger female, amenorrhea may occur and in older, bleeding may
occur.
↑aldosterone hormone may cause sodium water retention and potassium
loss.
Peripheral neuropathy:
Probably due to dietary deficiency of thiamine, folic acid and cobalamin.
Clinical manifestations:
According to book According to patient
Compensated
• Intermittent mild fever
• Vascular spiders
• Palmar erythema (reddened
palms)
• Unexplained epistaxis
• Ankle edema
• Vague morning indigestion
• Flatulent dyspepsia
• Abdominal pain
• Firm, enlarged liver
• Splenomegaly
Decompensate
• Ascites
• Jaundice
• Weakness
Hepatomegaly
Jaundice (bilirubin total 2.2 mg /dl)
Moderate Ascites
Bilateral pedal edema
Losses of appetite
Abdominal pain
dull and heavy feeling in right upper
quadrant
weakness, fatigue, nausea, weight
loss
Anemia (pale mucosa ,)
Mild shortness of breathing
• Ascites
• Jaundice
• Weight loss
and impotence with loss of libido due to increased estrogen level.
In younger female, amenorrhea may occur and in older, bleeding may
occur.
↑aldosterone hormone may cause sodium water retention and potassium
loss.
Peripheral neuropathy:
Probably due to dietary deficiency of thiamine, folic acid and cobalamin.
Clinical manifestations:
According to book According to patient
Compensated
• Intermittent mild fever
• Vascular spiders
• Palmar erythema (reddened
palms)
• Unexplained epistaxis
• Ankle edema
• Vague morning indigestion
• Flatulent dyspepsia
• Abdominal pain
• Firm, enlarged liver
• Splenomegaly
Decompensate
• Ascites
• Jaundice
• Weakness
Hepatomegaly
Jaundice (bilirubin total 2.2 mg /dl)
Moderate Ascites
Bilateral pedal edema
Losses of appetite
Abdominal pain
dull and heavy feeling in right upper
quadrant
weakness, fatigue, nausea, weight
loss
Anemia (pale mucosa ,)
Mild shortness of breathing
• Ascites
• Jaundice
• Weight loss
• Muscle wasting
• Weight loss
• Continuous mild fever
• Clubbing of fingers
• Purpura (due to decreased
platelet count)
• Spontaneous bruising
• Epistaxis
• Hypotension
• Sparse body hair
• White nails
• Gonadal atrophy
Diagnosis according to book
• Liver function test : ↑alkaline phosphate, ALT,AST and y – glutamyl
transpeptidase ( GGT)
• Blood test: ↓ total protein, ↓ albumin, ↑ serum bilirubin and glubomin
• Prothombin time is prolong
• Liver cell biopsy to identify liver cell changes
• Ascites fluid test
• Liver ultrasound
• CT Scan
• Stool for occult blood
Endoscopy
Investigations
These are performed to assess the severity and type of liver disease.
Severity
■ Liver function. Serum albumin and prothrombin time are the best indicators
of liver function: the outlook is poor with an albumin level below 28 g/L. The
prothrombin time is prolonged commensurate with the severity of the liver
disease .
■ Liver biochemistry. This can be normal, depending on the severity of
cirrhosis. In most cases there is at least a slight elevation in the serum ALP
• Weight loss
• Continuous mild fever
• Clubbing of fingers
• Purpura (due to decreased
platelet count)
• Spontaneous bruising
• Epistaxis
• Hypotension
• Sparse body hair
• White nails
• Gonadal atrophy
Diagnosis according to book
• Liver function test : ↑alkaline phosphate, ALT,AST and y – glutamyl
transpeptidase ( GGT)
• Blood test: ↓ total protein, ↓ albumin, ↑ serum bilirubin and glubomin
• Prothombin time is prolong
• Liver cell biopsy to identify liver cell changes
• Ascites fluid test
• Liver ultrasound
• CT Scan
• Stool for occult blood
Endoscopy
Investigations
These are performed to assess the severity and type of liver disease.
Severity
■ Liver function. Serum albumin and prothrombin time are the best indicators
of liver function: the outlook is poor with an albumin level below 28 g/L. The
prothrombin time is prolonged commensurate with the severity of the liver
disease .
■ Liver biochemistry. This can be normal, depending on the severity of
cirrhosis. In most cases there is at least a slight elevation in the serum ALP
and serum aminotransferases. In decompensated cirrhosis all
biochemistry is deranged.
■ Serum electrolytes. A low sodium indicates severe liver disease due to a
defect in free water clearance or to excess diuretic therapy.
■ Serum creatinine. An elevated concentration 130 mol/ L is a marker of
worse prognosis.In addition, serum -fetoprotein if 200 ng/mL is strongly
suggestive of the presence of a hepatocellular carcinoma.
Ultrasound examination. This can demonstrate changes in size and shape of the liver.
Fatty change and fibrosis produce a diffuse increased echogenicity. In
established cirrhosis there may be marginal nodularity of the liver surface and distortion of
the arterial vascular architecture. The patency of the portal and hepatic
veins can be evaluated. It is useful in detecting hepatocellular carcinoma. Elastography is
being used in diagnosis and follow-up to avoid liver biopsy.
■ CT scan
Arterial phase-contrast-enhanced scans are useful in the detection of hepatocellular
carcinoma.
■ Endoscopy is performed for the detection and treatment of varices, and portal
hypertensive gastropathy. Colonoscopy is occasionally performed for
colopathy.
■ MRI scan. This is useful in the diagnosis of benign tumours such as haemangiomas. MR
angiography can demonstrate the vascular anatomy and MR cholangiography the biliary
tree.
Liver biopsy
This is usually necessary to confirm the severity and type of liver disease. The core of liver
often fragments and sampling errors may occur in macronodular cirrhosis. Special stains are
required for iron and copper, and various immunocytochemical stains can identify viruses,
bile ducts and angiogenic structures. Chemical measurement of iron and copper is
necessary to confirm diagnosis of iron overload or Wilson’s disease. Adequate samples in
terms of length and number of complete portal tracts are necessary for diagnosis and for
staging/grading of chronic viral hepatitis.
Diagnostic Investigations in patient
According to Book According to Patient
biochemistry is deranged.
■ Serum electrolytes. A low sodium indicates severe liver disease due to a
defect in free water clearance or to excess diuretic therapy.
■ Serum creatinine. An elevated concentration 130 mol/ L is a marker of
worse prognosis.In addition, serum -fetoprotein if 200 ng/mL is strongly
suggestive of the presence of a hepatocellular carcinoma.
Ultrasound examination. This can demonstrate changes in size and shape of the liver.
Fatty change and fibrosis produce a diffuse increased echogenicity. In
established cirrhosis there may be marginal nodularity of the liver surface and distortion of
the arterial vascular architecture. The patency of the portal and hepatic
veins can be evaluated. It is useful in detecting hepatocellular carcinoma. Elastography is
being used in diagnosis and follow-up to avoid liver biopsy.
■ CT scan
Arterial phase-contrast-enhanced scans are useful in the detection of hepatocellular
carcinoma.
■ Endoscopy is performed for the detection and treatment of varices, and portal
hypertensive gastropathy. Colonoscopy is occasionally performed for
colopathy.
■ MRI scan. This is useful in the diagnosis of benign tumours such as haemangiomas. MR
angiography can demonstrate the vascular anatomy and MR cholangiography the biliary
tree.
Liver biopsy
This is usually necessary to confirm the severity and type of liver disease. The core of liver
often fragments and sampling errors may occur in macronodular cirrhosis. Special stains are
required for iron and copper, and various immunocytochemical stains can identify viruses,
bile ducts and angiogenic structures. Chemical measurement of iron and copper is
necessary to confirm diagnosis of iron overload or Wilson’s disease. Adequate samples in
terms of length and number of complete portal tracts are necessary for diagnosis and for
staging/grading of chronic viral hepatitis.
Diagnostic Investigations in patient
According to Book According to Patient
• Liver function test :
↑alkaline phosphate,
ALT,AST and y –
glutamyl transpeptidase (
GGT)
• Blood test: ↓ total protein,
↓ albumin, ↑ serum
bilirubin and glubomin
• Prothombin time is
prolong
• Liver cell biopsy to
identify liver cell changes
• Ascites fluid test
• Liver ultrasound
• CT Scan
•
Liver function test :
SGOT/ AST : 187 U/L
SGPT/ ALT: 88.0 U/L
Alkaline Phosphate: 124 IU/L
Total protein : 6.4 gm/dl
Albumin : 3.4 gm/dl
Prothombin time: 23.3 sec
INR : 1.8
Bilirubin Total: 2.2mg/dl
Creatinine : 2.0 mg /dl
Haemoglobin: 7.8 gm/dl
WBC : 11,600 Mm3
Platelets : 61,000 Mm3
USG: findings s/o cirrhosis of
Liver, Moderate Ascites
Others Investigations of patient
Date of
investigation
According to my patient Normal range
2068/07/13
Hematology
Hb :7.8gm /dl
WBC:11,600 mm3
Platelets :61,000 mm3
Prothombin Time (test):
23.3sec
Prothombin Time (control):
14.0 sec
INR : 1.8
Differential count
Neutrophil- 90%
Lymphocyte 10%
Esinophil-00
Basophil-00
HB% M-13-15 F-12-14
gm/dl
WBC-400O-1100mm3
Platelets 1,50,000-
4,00,000
Prothombin Time (test)
14-16 sec
Neutrophil-40-70%
Lymphocyte-30-35%
Esinophil -1-2%
Basophil-0-1%
↑alkaline phosphate,
ALT,AST and y –
glutamyl transpeptidase (
GGT)
• Blood test: ↓ total protein,
↓ albumin, ↑ serum
bilirubin and glubomin
• Prothombin time is
prolong
• Liver cell biopsy to
identify liver cell changes
• Ascites fluid test
• Liver ultrasound
• CT Scan
•
Liver function test :
SGOT/ AST : 187 U/L
SGPT/ ALT: 88.0 U/L
Alkaline Phosphate: 124 IU/L
Total protein : 6.4 gm/dl
Albumin : 3.4 gm/dl
Prothombin time: 23.3 sec
INR : 1.8
Bilirubin Total: 2.2mg/dl
Creatinine : 2.0 mg /dl
Haemoglobin: 7.8 gm/dl
WBC : 11,600 Mm3
Platelets : 61,000 Mm3
USG: findings s/o cirrhosis of
Liver, Moderate Ascites
Others Investigations of patient
Date of
investigation
According to my patient Normal range
2068/07/13
Hematology
Hb :7.8gm /dl
WBC:11,600 mm3
Platelets :61,000 mm3
Prothombin Time (test):
23.3sec
Prothombin Time (control):
14.0 sec
INR : 1.8
Differential count
Neutrophil- 90%
Lymphocyte 10%
Esinophil-00
Basophil-00
HB% M-13-15 F-12-14
gm/dl
WBC-400O-1100mm3
Platelets 1,50,000-
4,00,000
Prothombin Time (test)
14-16 sec
Neutrophil-40-70%
Lymphocyte-30-35%
Esinophil -1-2%
Basophil-0-1%
2068/07/16
Biochemistry- report
Blood sugar (R):129.0 mg/dl
Creatinine: 2mg/dl
Sodium : 142.7mmol/l
Potassium :3.45 mmol/l
Total Protein : 6.4 gm/dl
Albumin: 3.4 gm/dl
SGOT/AST : 187.0 U/L
AGPT/ALT: 88.0 U/L
Alkaline phosphates: 124.0
IU /L
Blood grouping:’’B’’
positive
Bilirubin Total: 2.2 mg/dl
Bilirubin Total: 0.8 mg /dl
ECG : Normal Sinus
rhythm, non specific T wave
abnormality
Urine RE/ME
Colour- light yellow
Reaction –Acidic
Albumin- Nil
Sugar-Nil
transparency- Clear
Pus Cell-2-4 /HPF
RBCs: Plenty
Epithelial cells- 3-4 /HPF
USG abdomen and pelvis:
Finding S/O Cirrhosis of
Liver
Moderate Ascites
Blood sugar (R): 60-180
mg/dl
Creatinine: 0.4-1.4 mg/dl
Sodium : 135-150 mmol/L
Potassium : 3.3-5.5
mmol/L
Total Protein :6-8 gm/dl
Albumin: 3.5-5.5 gm/dl
SGOT/AST : M ˂37 F ˂31
U/L
AGPT/ALT ˂40.0 U/L
Alkaline phosphates : M-
64 -306 F: 84-306
Up to 15 yrs: <644
Up to 17 yrs : <483
Bilirubin Total: 0.4-1.0
mg/dl
Bilirubin Total: 0.1-0.4
ECG : Sinus rhythm
Urine R/E:Acidic
Appearance: Clear
Color: P. yellow
WBC:3-5/HPF
Epithelial cell: 2-4/HPF
USG abdomen and
pelvis: Normal scan
Biochemistry- report
Blood sugar (R):129.0 mg/dl
Creatinine: 2mg/dl
Sodium : 142.7mmol/l
Potassium :3.45 mmol/l
Total Protein : 6.4 gm/dl
Albumin: 3.4 gm/dl
SGOT/AST : 187.0 U/L
AGPT/ALT: 88.0 U/L
Alkaline phosphates: 124.0
IU /L
Blood grouping:’’B’’
positive
Bilirubin Total: 2.2 mg/dl
Bilirubin Total: 0.8 mg /dl
ECG : Normal Sinus
rhythm, non specific T wave
abnormality
Urine RE/ME
Colour- light yellow
Reaction –Acidic
Albumin- Nil
Sugar-Nil
transparency- Clear
Pus Cell-2-4 /HPF
RBCs: Plenty
Epithelial cells- 3-4 /HPF
USG abdomen and pelvis:
Finding S/O Cirrhosis of
Liver
Moderate Ascites
Blood sugar (R): 60-180
mg/dl
Creatinine: 0.4-1.4 mg/dl
Sodium : 135-150 mmol/L
Potassium : 3.3-5.5
mmol/L
Total Protein :6-8 gm/dl
Albumin: 3.5-5.5 gm/dl
SGOT/AST : M ˂37 F ˂31
U/L
AGPT/ALT ˂40.0 U/L
Alkaline phosphates : M-
64 -306 F: 84-306
Up to 15 yrs: <644
Up to 17 yrs : <483
Bilirubin Total: 0.4-1.0
mg/dl
Bilirubin Total: 0.1-0.4
ECG : Sinus rhythm
Urine R/E:Acidic
Appearance: Clear
Color: P. yellow
WBC:3-5/HPF
Epithelial cell: 2-4/HPF
USG abdomen and
pelvis: Normal scan
068/07/17
Creatinine: 1.7 mg/dl
Platelets :67,000 mm3
Hb : 10.2 gm /dl
Platelets :92,000 mm3
Creatinine: 0.4-1.4 mg/dl
Platelets 1,50,000-
4,00,000 mm3
Management (According To Book)
Medical management
• Monitor for complications: Ascites, bleeding esophageal varices and hepatic
encephalopathy and if occurs manage them accordingly.
• Many medicines have been studied, such as steroids, penicillamine
(Cuprimine, Depen), and an anti-inflammatory agent (colchicine), but they
have not been shown to prolong survival or improve survival rate.
• Researchers are studying various experimental treatments for cirrhosis.
Creatinine: 1.7 mg/dl
Platelets :67,000 mm3
Hb : 10.2 gm /dl
Platelets :92,000 mm3
Creatinine: 0.4-1.4 mg/dl
Platelets 1,50,000-
4,00,000 mm3
Management (According To Book)
Medical management
• Monitor for complications: Ascites, bleeding esophageal varices and hepatic
encephalopathy and if occurs manage them accordingly.
• Many medicines have been studied, such as steroids, penicillamine
(Cuprimine, Depen), and an anti-inflammatory agent (colchicine), but they
have not been shown to prolong survival or improve survival rate.
• Researchers are studying various experimental treatments for cirrhosis.
Surgical management
• The only surgery that has been proven to improve the chances of long-term
survival is liver transplantation.
• About 80-90 percent of people who undergo liver transplantation survive.
Maximize liver function:
• The diet should be adequate calories and protein (75- 100 gm/day) unless
hepatic encephalopathy is present, in which case protein is limited.
• Restrict fluid and sodium if edema or fluid retention is present.
• Diuretic, thiazide – potassium supplement.
• The B vitamins and fat soluble vitamins (A, D, E, K).
• Adequate rest is needed to maximize regeneration of liver cells.
• Corticosteroids drugs to improve liver function in post necrotic cirrhosis.
Treat underlying cause:
if cirrhosis is from heavy alcohol use, the treatment is to completely stop
drinking alcohol.
If cirrhosis is caused by hepatitis C, then the hepatitis C virus is treated
with medicine
Prevent Infection:
by adequate rest, appropriate diet, avoidance of hepatotoxic substances.
Beta-blocker or nitrate
• For portal hypertension. Beta-blockers can lower the pressure in the
varices and reduce the risk of bleeding. Gastrointestinal bleeding requires
an immediate upper endoscopy to look for esophageal varices.
Complications
Portal hypertension:
• The nodules and scar tissue can compress hepatic veins within the liver.
• This causes the blood pressure within the liver to be high, a condition known
as portal hypertension.
• The only surgery that has been proven to improve the chances of long-term
survival is liver transplantation.
• About 80-90 percent of people who undergo liver transplantation survive.
Maximize liver function:
• The diet should be adequate calories and protein (75- 100 gm/day) unless
hepatic encephalopathy is present, in which case protein is limited.
• Restrict fluid and sodium if edema or fluid retention is present.
• Diuretic, thiazide – potassium supplement.
• The B vitamins and fat soluble vitamins (A, D, E, K).
• Adequate rest is needed to maximize regeneration of liver cells.
• Corticosteroids drugs to improve liver function in post necrotic cirrhosis.
Treat underlying cause:
if cirrhosis is from heavy alcohol use, the treatment is to completely stop
drinking alcohol.
If cirrhosis is caused by hepatitis C, then the hepatitis C virus is treated
with medicine
Prevent Infection:
by adequate rest, appropriate diet, avoidance of hepatotoxic substances.
Beta-blocker or nitrate
• For portal hypertension. Beta-blockers can lower the pressure in the
varices and reduce the risk of bleeding. Gastrointestinal bleeding requires
an immediate upper endoscopy to look for esophageal varices.
Complications
Portal hypertension:
• The nodules and scar tissue can compress hepatic veins within the liver.
• This causes the blood pressure within the liver to be high, a condition known
as portal hypertension.
• Portal venous pressure is more than 15mmHg or 20 cm of water.
• Is characterized by ↑venous pressure in the portal circulation,
spleenomegaly, large collateral vein, ascites, systemic hypertension, and
esophageal varices.
• The common area to form collateral channels are in the lower esophagus(
the anastomosis of the left gastric vein and azygos vein), the parietal
peritoneum, rectum.
• High pressures within blood vessels of the liver occur in 60% of people who
have cirrhosis
Esophageal Varices:
• Esophageal Varices are a complex of tortuous veins at the lower end of the
esophageal enlarged and swollen as a result of portal hypertension.
• 10-30% of UGI bleeding due to rupture of varices.
• 80% bleeding due to esophageal Varices.
• 20% due to gastric varices.
Peripheral edema and Ascites:
• Edema results from decreased colloidal oncotic pressure from impaired
liver synthesis of albumin (hypoalbuminia)
• Ascites is the accumulation of serous fluid in the peritoneal cavity.
• Protein move from the blood vessels via the larger pore of sinusoids into the
lymph space.
• When the lymphatic system is unable to carry off the excess protein and
water, they leak through the liver capsule into the peritoneal cavity.
Hepatic encephalopathy:
• Hepatic encephalopathy is a neuropsychiatric manifestation of liver damage.
• It can occur in any condition in which liver damage causes ammonia to
enter the systemic circulation without liver detoxification.
• Liver is unable to convert ammonia to urea. The ammonia crosses the blood
brain barrier and produces neurologic toxic manifestations
• Clinical manifestations include changes in neurological and mental
responsiveness, ranging from sleep disturbances to lethargy to deep coma.
• Grading systems are: early stage (stage 0 and 1) euphoria, depression,
• Is characterized by ↑venous pressure in the portal circulation,
spleenomegaly, large collateral vein, ascites, systemic hypertension, and
esophageal varices.
• The common area to form collateral channels are in the lower esophagus(
the anastomosis of the left gastric vein and azygos vein), the parietal
peritoneum, rectum.
• High pressures within blood vessels of the liver occur in 60% of people who
have cirrhosis
Esophageal Varices:
• Esophageal Varices are a complex of tortuous veins at the lower end of the
esophageal enlarged and swollen as a result of portal hypertension.
• 10-30% of UGI bleeding due to rupture of varices.
• 80% bleeding due to esophageal Varices.
• 20% due to gastric varices.
Peripheral edema and Ascites:
• Edema results from decreased colloidal oncotic pressure from impaired
liver synthesis of albumin (hypoalbuminia)
• Ascites is the accumulation of serous fluid in the peritoneal cavity.
• Protein move from the blood vessels via the larger pore of sinusoids into the
lymph space.
• When the lymphatic system is unable to carry off the excess protein and
water, they leak through the liver capsule into the peritoneal cavity.
Hepatic encephalopathy:
• Hepatic encephalopathy is a neuropsychiatric manifestation of liver damage.
• It can occur in any condition in which liver damage causes ammonia to
enter the systemic circulation without liver detoxification.
• Liver is unable to convert ammonia to urea. The ammonia crosses the blood
brain barrier and produces neurologic toxic manifestations
• Clinical manifestations include changes in neurological and mental
responsiveness, ranging from sleep disturbances to lethargy to deep coma.
• Grading systems are: early stage (stage 0 and 1) euphoria, depression,
apathy, irritability, memory loss, confusion, drowsiness, insomnia.
• Lactulose , low-protein diet improves symptoms in 75 percent of cases.
• Later stages( stage 2 and 3) include slow and slurred speech , impaired
judgment, hiccup slow and deep respiration, babinski reflex, stage 4 include
disorientation to time , place, person.
Hepatorenal syndrome:
• Hepatorenal syndrome is a serious complication of cirrhosis characterized
by functional renal failure with advancing azotemia, oliguria, and ascites.
MEDIAL MANAGEMENT IN PATIENT
Fluid restriction < 1000 ml /Day
Low salt diet
Egg white BD
Monitor Daily Weight and abdominal girth
Advice for Completely stop of alcohol
Inj. Vitamin K 1 amp I/V OD x 3 Days
Arrange and transfuse 2 pint of FFP
Arrange and transfuse 1 pint whole blood.
Inj. Optineurone 1 amp to be added in 5% dextrose
Others Supportive Managements
Inj .Taxim 1 gram TDS x 5 days
Tab Lasilactone 1 tab Po OD x 5 days
Tab Pantium 40 mg Po OD x 5days
Tab Tone 100 PO BD x 5 days
Tab Usoliv 300mg PO BD x 5days
Inj. Optineurone 1 amp to be added in 5% dextrose x 3 days
Nursing management :
Assessment
Assess the client client closely for the presence of early manifestations
such as :
Hepatomegaly
Carefully check the laboratory data.
• Lactulose , low-protein diet improves symptoms in 75 percent of cases.
• Later stages( stage 2 and 3) include slow and slurred speech , impaired
judgment, hiccup slow and deep respiration, babinski reflex, stage 4 include
disorientation to time , place, person.
Hepatorenal syndrome:
• Hepatorenal syndrome is a serious complication of cirrhosis characterized
by functional renal failure with advancing azotemia, oliguria, and ascites.
MEDIAL MANAGEMENT IN PATIENT
Fluid restriction < 1000 ml /Day
Low salt diet
Egg white BD
Monitor Daily Weight and abdominal girth
Advice for Completely stop of alcohol
Inj. Vitamin K 1 amp I/V OD x 3 Days
Arrange and transfuse 2 pint of FFP
Arrange and transfuse 1 pint whole blood.
Inj. Optineurone 1 amp to be added in 5% dextrose
Others Supportive Managements
Inj .Taxim 1 gram TDS x 5 days
Tab Lasilactone 1 tab Po OD x 5 days
Tab Pantium 40 mg Po OD x 5days
Tab Tone 100 PO BD x 5 days
Tab Usoliv 300mg PO BD x 5days
Inj. Optineurone 1 amp to be added in 5% dextrose x 3 days
Nursing management :
Assessment
Assess the client client closely for the presence of early manifestations
such as :
Hepatomegaly
Carefully check the laboratory data.
As the disease progresses , assess the manifestations of
complications of cirrhosis such as ascites, portal hypertension
or hepatic encephalopathy
History taking: past and present health history (alcohol intake, medication,
infection etc) chief complain sign and symptoms of disease
Physical examination
Psychosocial assessment
Nursing Diagnosis
• Ineffective tissue perfusion related to bleeding tendencies and varices that may
hemorrhage
Goal
• Hemorrhage will be prevented as evidenced by absence of bleeding, normal
vital sign and urine output of at least 0.5 ml/kg/hour
Interventions :
• Assess patient’s condition
• Monitor for hemorrhage bleeding from gums, melena, hematuria,
hematemasis.
• Assess vital sign for sign of shock
• Monitor urine output
• Protect patient from physical trauma to prevent hemorrhage
• Avoid unnecessary injection and apply gentle pressure after injection.
• Instruct the client to avoid vigorous nose blowing, straining with bowel
movement.
• Provide stool softener to prevent straining with rupture of varices.
• Advice to use soft tooth brush to prevent gum bleeding.
Activity intolerance related to bed rest, fatigue, lack of energy, and altered
respiratory function secondary to ascites.
Outcomes
The patient will maintain a balance between rest and activity as evidenced
complications of cirrhosis such as ascites, portal hypertension
or hepatic encephalopathy
History taking: past and present health history (alcohol intake, medication,
infection etc) chief complain sign and symptoms of disease
Physical examination
Psychosocial assessment
Nursing Diagnosis
• Ineffective tissue perfusion related to bleeding tendencies and varices that may
hemorrhage
Goal
• Hemorrhage will be prevented as evidenced by absence of bleeding, normal
vital sign and urine output of at least 0.5 ml/kg/hour
Interventions :
• Assess patient’s condition
• Monitor for hemorrhage bleeding from gums, melena, hematuria,
hematemasis.
• Assess vital sign for sign of shock
• Monitor urine output
• Protect patient from physical trauma to prevent hemorrhage
• Avoid unnecessary injection and apply gentle pressure after injection.
• Instruct the client to avoid vigorous nose blowing, straining with bowel
movement.
• Provide stool softener to prevent straining with rupture of varices.
• Advice to use soft tooth brush to prevent gum bleeding.
Activity intolerance related to bed rest, fatigue, lack of energy, and altered
respiratory function secondary to ascites.
Outcomes
The patient will maintain a balance between rest and activity as evidenced
by the absence of fatigue
Interventions:
• Assess level of activity tolerance and degree of fatigue, lethargy, and malaise
when performing routine ADLs.
• Assist with activities and hygiene when fatigued.
• Encourage rest when fatigued or when abdominal pain or discomfort
occurs.
• Assist with selection and pacing of desired activities and exercise.
• Provide diet high in carbohydrates with protein intake consistent with liver
function.
• Administer supplemental vitamins (A, B complex, C, and K).
Impaired skin integrity related to pruritus from jaundice and edema
Goal: ‘Decrease potential for pressure ulcer development; breaks in skin
integrity’
Interventions:
• Assess degree of discomfort related to pruritus and edema.
• Note and record degree of jaundice and extent of edema.
• Keep patient’s fingernails short and smooth.
• Provide frequent skin care; avoid use of soaps and alcohol-based lotions.
• Massage every 2 hours with emollients; turn every 2 hours
• Initiate use of alternating-pressure mattress or low air loss bed.
• Recommend avoiding use of harsh detergents.
• Assess skin integrity every 4–8 hours. Instruct patient and family in this
activity.
• Restrict sodium as prescribed.
• Perform range of motion exercises every 4 hours; elevate edematous
extremities whenever possible.
High risk for injury related to altered clotting mechanisms and altered level of
consciousness
Interventions:
• Assess level of activity tolerance and degree of fatigue, lethargy, and malaise
when performing routine ADLs.
• Assist with activities and hygiene when fatigued.
• Encourage rest when fatigued or when abdominal pain or discomfort
occurs.
• Assist with selection and pacing of desired activities and exercise.
• Provide diet high in carbohydrates with protein intake consistent with liver
function.
• Administer supplemental vitamins (A, B complex, C, and K).
Impaired skin integrity related to pruritus from jaundice and edema
Goal: ‘Decrease potential for pressure ulcer development; breaks in skin
integrity’
Interventions:
• Assess degree of discomfort related to pruritus and edema.
• Note and record degree of jaundice and extent of edema.
• Keep patient’s fingernails short and smooth.
• Provide frequent skin care; avoid use of soaps and alcohol-based lotions.
• Massage every 2 hours with emollients; turn every 2 hours
• Initiate use of alternating-pressure mattress or low air loss bed.
• Recommend avoiding use of harsh detergents.
• Assess skin integrity every 4–8 hours. Instruct patient and family in this
activity.
• Restrict sodium as prescribed.
• Perform range of motion exercises every 4 hours; elevate edematous
extremities whenever possible.
High risk for injury related to altered clotting mechanisms and altered level of
consciousness
Intervention
• Assess level of consciousness and cognitive level.
• Provide safe environment (pad side rails, remove obstacles in room, prevent
falls).
• Provide frequent surveillance to orient patient and avoid use of restraints.
• Replace sharp objects (razors) with safer terms.
• Observe each stool for color, consistency, and amount.
• Be alert for symptoms of anxiety, epigastric fullness, weakness, and
restlessness.
• Test each stool and emesis for occult blood.
• Observe for hemorrhagic manifestations: ecchymosis, epistaxis petechiae,
and bleeding gums.
• Record vital signs at frequent intervals, depending on patient acuity (every
1–4 hours).
• Keep patient quiet and limit activity.
Disturbed body image related to changes in appearance, and role function.
Goal: ‘Patient verbalizes feelings consistent with improvement of body image and
self-esteem’
Intervention:
• Assess changes in appearance and the meaning these changes have for
patient and family.
• Encourage patient to verbalize reactions and feelings about these changes.
• Assess patient’s and family’s previous coping strategies.
• Assist patient in identifying short-term goals.
• Encourage and assist patient in decision making about care.
• Identify with patient resources to provide additional support (counselor,
spiritual advisor).
• Assist patient in identifying previous practices that may have been harmful
to self (alcohol and drug abuse).
Fluid volume excess related to ascites and edema formation
Goal: Restoration of normal fluid volume
• Assess level of consciousness and cognitive level.
• Provide safe environment (pad side rails, remove obstacles in room, prevent
falls).
• Provide frequent surveillance to orient patient and avoid use of restraints.
• Replace sharp objects (razors) with safer terms.
• Observe each stool for color, consistency, and amount.
• Be alert for symptoms of anxiety, epigastric fullness, weakness, and
restlessness.
• Test each stool and emesis for occult blood.
• Observe for hemorrhagic manifestations: ecchymosis, epistaxis petechiae,
and bleeding gums.
• Record vital signs at frequent intervals, depending on patient acuity (every
1–4 hours).
• Keep patient quiet and limit activity.
Disturbed body image related to changes in appearance, and role function.
Goal: ‘Patient verbalizes feelings consistent with improvement of body image and
self-esteem’
Intervention:
• Assess changes in appearance and the meaning these changes have for
patient and family.
• Encourage patient to verbalize reactions and feelings about these changes.
• Assess patient’s and family’s previous coping strategies.
• Assist patient in identifying short-term goals.
• Encourage and assist patient in decision making about care.
• Identify with patient resources to provide additional support (counselor,
spiritual advisor).
• Assist patient in identifying previous practices that may have been harmful
to self (alcohol and drug abuse).
Fluid volume excess related to ascites and edema formation
Goal: Restoration of normal fluid volume
Intervention:
• Restrict sodium and fluid intake if prescribed.
• Administer diuretics, potassium, and protein supplements as prescribed.
• Record intake and output every 1 to 8 hours depending on response to
intervention and on patient acuity.
• Measure and record abdominal girth and weight daily.
• Explain rationale for sodium and fluid restriction.
• Prepare patient and assist with paracentesis
Risk for imbalanced body temperature: hyperthermia related to inflammatory
process of cirrhosis or hepatitis
Goal: Maintenance of normal body temperature, free from infection
• Record temperature regularly (every4 hours).
• Encourage fluid intake.
• Apply cool sponges or icebag for elevated temperature.
• Administer antibiotics as prescribed.
• Avoid exposure to infections.
• Keep patient at rest while temperature is elevated.
• Assess for abdominal pain, tenderness
Ineffective breathing pattern related to ascites and restriction of thoracic
excursion secondary to ascites, abdominal distention, and fluid in the thoracic
cavity.
Goal: Improved respiratory status
Intervention
Elevate head of bed to at least 30 degrees
Conserve patient’s strength by providing rest periods and assisting with
activities.
Change position every 2 hours.
Assist with paracentesis or thoracentesis.
• Restrict sodium and fluid intake if prescribed.
• Administer diuretics, potassium, and protein supplements as prescribed.
• Record intake and output every 1 to 8 hours depending on response to
intervention and on patient acuity.
• Measure and record abdominal girth and weight daily.
• Explain rationale for sodium and fluid restriction.
• Prepare patient and assist with paracentesis
Risk for imbalanced body temperature: hyperthermia related to inflammatory
process of cirrhosis or hepatitis
Goal: Maintenance of normal body temperature, free from infection
• Record temperature regularly (every4 hours).
• Encourage fluid intake.
• Apply cool sponges or icebag for elevated temperature.
• Administer antibiotics as prescribed.
• Avoid exposure to infections.
• Keep patient at rest while temperature is elevated.
• Assess for abdominal pain, tenderness
Ineffective breathing pattern related to ascites and restriction of thoracic
excursion secondary to ascites, abdominal distention, and fluid in the thoracic
cavity.
Goal: Improved respiratory status
Intervention
Elevate head of bed to at least 30 degrees
Conserve patient’s strength by providing rest periods and assisting with
activities.
Change position every 2 hours.
Assist with paracentesis or thoracentesis.
Explain procedure and its purpose to patient.
Have patient void before paracentesis.
Support and maintain position during procedure.
Record both the amount and the character of fluid aspirated.
Observe for evidence of coughing, increasing dyspnea, or pulse rate.
Application of Nursing Theory
Virginia Henderson’s independence theory
Henderson defined nursing as , “ the unique function of the nurse is to
assist the individual, sick or well , in the performance of those activities
contributing to health or its recovery ( or to peaceful death ) that he would
perform unaided if he had the necessary strength, will or knowledge. And to
do this in such a way as to help him gain independence of such assistance as
soon as possible.
The 14 Basic components of Nursing Care
1. Breathe normally.
2. Eat and drink adequately.
3. Eliminate body wastes.
4. Move and maintain desirable postures.
5. Sleep and rest.
6. Select suitable clothes-dress and undress.
7. Maintain body temperature within normal range by adjusting clothing and
modifying environment
8. Keep the body clean and well groomed and protect the integument
9. Avoid dangers in the environment and avoid injuring others.
10. Communicate with others in expressing emotions, needs, fears, or opinions.
11. Worship according to one’s faith.
12. Work in such a way that there is a sense of accomplishment.
13. Play or participate in various forms of recreation.
14. Learn, discover, or satisfy the curiosity that leads to normal development
and health and use the available health facilities.
Have patient void before paracentesis.
Support and maintain position during procedure.
Record both the amount and the character of fluid aspirated.
Observe for evidence of coughing, increasing dyspnea, or pulse rate.
Application of Nursing Theory
Virginia Henderson’s independence theory
Henderson defined nursing as , “ the unique function of the nurse is to
assist the individual, sick or well , in the performance of those activities
contributing to health or its recovery ( or to peaceful death ) that he would
perform unaided if he had the necessary strength, will or knowledge. And to
do this in such a way as to help him gain independence of such assistance as
soon as possible.
The 14 Basic components of Nursing Care
1. Breathe normally.
2. Eat and drink adequately.
3. Eliminate body wastes.
4. Move and maintain desirable postures.
5. Sleep and rest.
6. Select suitable clothes-dress and undress.
7. Maintain body temperature within normal range by adjusting clothing and
modifying environment
8. Keep the body clean and well groomed and protect the integument
9. Avoid dangers in the environment and avoid injuring others.
10. Communicate with others in expressing emotions, needs, fears, or opinions.
11. Worship according to one’s faith.
12. Work in such a way that there is a sense of accomplishment.
13. Play or participate in various forms of recreation.
14. Learn, discover, or satisfy the curiosity that leads to normal development
and health and use the available health facilities.
ASSESSMENT OF PATIENT ON THE BASIS OF 14 BASIS COMPONENTS
1 Breathe normally.
Patient has difficulty in breathing especially in supine position due to ascites
2 Eat and drink adequately.
Patient is taking so limited food
She has loss of appetite
She has restricted fluid intake
3 Eliminate body wastes.
Patient has no problem related to bladder and bowel empty but her serum
creatinine level is high (2.0 gm/dl)
4 Sleep and rest
Patient has disturb sleep
She has discomfort due to ascites
5 Select suitable clothes-dress and undress.
Patient has no significant problems in this area.
6 Maintain body temperature within normal range by adjusting clothing
and modifying environment
Patient has sometimes mild fever
7 Keep the body clean and well groomed and protect the integument
Patient looks dirty
She has risk for skin breakdown due to edema
8 Move and maintain desirable postures.
Patient has only imitated mobility
9. Avoid dangers in the environment and avoid injuring others.
1 Breathe normally.
Patient has difficulty in breathing especially in supine position due to ascites
2 Eat and drink adequately.
Patient is taking so limited food
She has loss of appetite
She has restricted fluid intake
3 Eliminate body wastes.
Patient has no problem related to bladder and bowel empty but her serum
creatinine level is high (2.0 gm/dl)
4 Sleep and rest
Patient has disturb sleep
She has discomfort due to ascites
5 Select suitable clothes-dress and undress.
Patient has no significant problems in this area.
6 Maintain body temperature within normal range by adjusting clothing
and modifying environment
Patient has sometimes mild fever
7 Keep the body clean and well groomed and protect the integument
Patient looks dirty
She has risk for skin breakdown due to edema
8 Move and maintain desirable postures.
Patient has only imitated mobility
9. Avoid dangers in the environment and avoid injuring others.
patient has no significant problems in these areas as the environment is safe
for patient
10. Communicate with others in expressing emotions, needs, fears, or
opinions.
Patient is communicating limited to health team members because she has
some language problem
11. Worship according to one’s faith.
Patient has some problem in this areas because she has no appropriate
environment for worship according to own faith.
12. Work in such a way that there is a sense of accomplishment.
Patient has only limited involvement in activities of daily living
13. Play or participate in various forms of recreation.
she does not seems to interested in recreational activities like talking to
other patients , and staffs
14. Learn, discover, or satisfy the curiosity that leads to normal
development and health and use the available health facilities
She is not interested to learn .She is not curious towards environment
NURSING CARE PLAN
NURSING DIAGNOSIS
Activity intolerance related to bed rest, fatigue, lack of energy, and altered
respiratory function secondary to ascites.
GOAL
The patient will maintain a balance between rest and activity as evidenced
by the absence of fatigue
PLANNING
for patient
10. Communicate with others in expressing emotions, needs, fears, or
opinions.
Patient is communicating limited to health team members because she has
some language problem
11. Worship according to one’s faith.
Patient has some problem in this areas because she has no appropriate
environment for worship according to own faith.
12. Work in such a way that there is a sense of accomplishment.
Patient has only limited involvement in activities of daily living
13. Play or participate in various forms of recreation.
she does not seems to interested in recreational activities like talking to
other patients , and staffs
14. Learn, discover, or satisfy the curiosity that leads to normal
development and health and use the available health facilities
She is not interested to learn .She is not curious towards environment
NURSING CARE PLAN
NURSING DIAGNOSIS
Activity intolerance related to bed rest, fatigue, lack of energy, and altered
respiratory function secondary to ascites.
GOAL
The patient will maintain a balance between rest and activity as evidenced
by the absence of fatigue
PLANNING
Assess level of activity tolerance and degree of fatigue, lethargy, and malaise
when performing routine ADLs.
Assist with activities and hygiene when fatigued.
Encourage rest when fatigued or when abdominal pain or discomfort
occurs.
Provide diet high in carbohydrates with protein intake consistent with liver
function.
Administer supplemental vitamins (A, B complex, C, and K).
INTERVENTION
Assessed level of activity tolerance and degree of fatigue, lethargy, and
malaise when performing routine ADLs.
Assisted with activities and hygiene when fatigued.
Encouraged rest when fatigued or when abdominal pain or discomfort
occurs.
Encouraged to take diet high in carbohydrates.
Encouraged to take egg white BD
Administered supplemental vitamins B complex, (inj. neurobion in 5%
dextrose) as prescribed
Administered vit. K as prescribed
Evaluation:
My goal was partially met as patient was complained of less fatigue than before.
NURSING DIAGNOSIS
Fluid volume excess related to ascites and edema formation
Goal
Restoration of normal fluid volume
PLANNING
Restrict sodium and fluid intake if prescribed.
Administer diuretics, potassium, and protein supplements as prescribed.
Record intake and output every 1 to 8 hours depending on response to
when performing routine ADLs.
Assist with activities and hygiene when fatigued.
Encourage rest when fatigued or when abdominal pain or discomfort
occurs.
Provide diet high in carbohydrates with protein intake consistent with liver
function.
Administer supplemental vitamins (A, B complex, C, and K).
INTERVENTION
Assessed level of activity tolerance and degree of fatigue, lethargy, and
malaise when performing routine ADLs.
Assisted with activities and hygiene when fatigued.
Encouraged rest when fatigued or when abdominal pain or discomfort
occurs.
Encouraged to take diet high in carbohydrates.
Encouraged to take egg white BD
Administered supplemental vitamins B complex, (inj. neurobion in 5%
dextrose) as prescribed
Administered vit. K as prescribed
Evaluation:
My goal was partially met as patient was complained of less fatigue than before.
NURSING DIAGNOSIS
Fluid volume excess related to ascites and edema formation
Goal
Restoration of normal fluid volume
PLANNING
Restrict sodium and fluid intake if prescribed.
Administer diuretics, potassium, and protein supplements as prescribed.
Record intake and output every 1 to 8 hours depending on response to
intervention and on patient acuity.
Measure and record abdominal girth and weight daily.
Prepare patient and assist with paracentesis if needed.
INTERVENTION
Restricted sodium as prescribed
Restricted fluid intake up to 1000ml/day as prescribed.
Administered diuretics (tab lasilactone 1 tab OD) as prescribed.
Recorded intake and output strictly.
Measured and recorded abdominal girth and weight daily.
EVALUATION
My goal was not fulfilled as patient’s edema and ascites was increased than
before
NURSING DIAGNOSIS
Ineffective breathing pattern related to ascites and restriction of thoracic
excursion secondary to ascites
GOAL
Improved respiratory status
PLANNING
Elevate head of bed to at least 30 degrees
Conserve patient’s strength by providing rest periods and assisting with
activities.
Change position every 2 hours.
Administer oxygen as needed
INTERVENTIONS
Elevated head of bed (semi fowler’s position)
Conserved patient’s strength by providing rest periods and assisting with
activities.
Measure and record abdominal girth and weight daily.
Prepare patient and assist with paracentesis if needed.
INTERVENTION
Restricted sodium as prescribed
Restricted fluid intake up to 1000ml/day as prescribed.
Administered diuretics (tab lasilactone 1 tab OD) as prescribed.
Recorded intake and output strictly.
Measured and recorded abdominal girth and weight daily.
EVALUATION
My goal was not fulfilled as patient’s edema and ascites was increased than
before
NURSING DIAGNOSIS
Ineffective breathing pattern related to ascites and restriction of thoracic
excursion secondary to ascites
GOAL
Improved respiratory status
PLANNING
Elevate head of bed to at least 30 degrees
Conserve patient’s strength by providing rest periods and assisting with
activities.
Change position every 2 hours.
Administer oxygen as needed
INTERVENTIONS
Elevated head of bed (semi fowler’s position)
Conserved patient’s strength by providing rest periods and assisting with
activities.
Changed position every 2 hours.
Encouraged for deep breathing and coughing exercise
Evaluation
My goal was partially met, as patient reported the improved breathing comfort
than before
NURSING DIAGNOSIS
Risk for impaired skin integrity related to pruritus from jaundice and edema
GOAL
Decrease potential for pressure ulcer development; breaks in skin integrity
INTERVENTION
Assessed the degree of discomfort related to pruritus and edema.
Kept the patient’s fingernails short and smooth.
Provided frequent skin care by changing the daily clothes and encouraged
to apply powder especially in-between the fingers and toes.
Changed the patient’s position in every 2 hours
Assessed skin integrity in every 4–8 hours. Instruct patient and family in
this activity.
Restricted sodium as prescribed.
Encouraged to Perform range of motion exercises every 4 hours;
Elevated edematous extremities.
EVALUATION
My goal was fully met, as patient did not developed pressure sore and any other
skin lesion during hospitalization
NURSING DIAGNOSIS
High risk for injury / bleeding related to altered clotting mechanisms.
GOAL
Bleeding tendency will be minimized
Encouraged for deep breathing and coughing exercise
Evaluation
My goal was partially met, as patient reported the improved breathing comfort
than before
NURSING DIAGNOSIS
Risk for impaired skin integrity related to pruritus from jaundice and edema
GOAL
Decrease potential for pressure ulcer development; breaks in skin integrity
INTERVENTION
Assessed the degree of discomfort related to pruritus and edema.
Kept the patient’s fingernails short and smooth.
Provided frequent skin care by changing the daily clothes and encouraged
to apply powder especially in-between the fingers and toes.
Changed the patient’s position in every 2 hours
Assessed skin integrity in every 4–8 hours. Instruct patient and family in
this activity.
Restricted sodium as prescribed.
Encouraged to Perform range of motion exercises every 4 hours;
Elevated edematous extremities.
EVALUATION
My goal was fully met, as patient did not developed pressure sore and any other
skin lesion during hospitalization
NURSING DIAGNOSIS
High risk for injury / bleeding related to altered clotting mechanisms.
GOAL
Bleeding tendency will be minimized
PLANNING
Observe for hemorrhagic manifestations:such as ecchymosis, epistaxis
,petechiae, and bleeding gums.
Observe each stool for color, consistency, and amount.
Be alert for symptoms of anxiety, epigastric fullness, weakness, and
restlessness.
Test each stool and emesis for occult blood.
Record vital signs at frequent intervals, depending on patient acuity (every
1–4 hours).
Administer vit K as prescribed
Transfuse fresh frozen plasma as prescribed.
INTERVENTION
Observed for hemorrhagic manifestations: such as ecchymosis, epistaxis
,petechiae, and bleeding gums.
Observed each stool for color, consistency, and amount.
Closely observed the symptoms of internal hemorrhage such as anxiety,
epigastric fullness, weakness, and restlessness.
Recorded vital signs at frequent intervals,
Administered vit K as prescribed
Transfused fresh frozen plasma as prescribed.
EVALUATION
My goal was fully met as the patient did not developed the sign of
haemorrhage during hospitalization.
Observe for hemorrhagic manifestations:such as ecchymosis, epistaxis
,petechiae, and bleeding gums.
Observe each stool for color, consistency, and amount.
Be alert for symptoms of anxiety, epigastric fullness, weakness, and
restlessness.
Test each stool and emesis for occult blood.
Record vital signs at frequent intervals, depending on patient acuity (every
1–4 hours).
Administer vit K as prescribed
Transfuse fresh frozen plasma as prescribed.
INTERVENTION
Observed for hemorrhagic manifestations: such as ecchymosis, epistaxis
,petechiae, and bleeding gums.
Observed each stool for color, consistency, and amount.
Closely observed the symptoms of internal hemorrhage such as anxiety,
epigastric fullness, weakness, and restlessness.
Recorded vital signs at frequent intervals,
Administered vit K as prescribed
Transfused fresh frozen plasma as prescribed.
EVALUATION
My goal was fully met as the patient did not developed the sign of
haemorrhage during hospitalization.
DAILY PROGRESS NOTE OF PATIENT
Date :- 2068/07/ 13
Admission day
A patient was admitted in male medical ward from OPD with history of
abdominal distention , bilateral pedal edema , mild shortness of breathing and
loss of appetite .
On admission patient’s vitals sign were:
B.P=110/60 mm of hg, R.R=22/min,
Pulse=98/min, Temp.=98ºf weight: 37kg
Patient’s general condition was ill looking.
Mild to moderate shortness of breathing was noticed.
USG abdomen and all base line investigation was ordered
MAJOR NURSING INTERVENTION
Admission procedure carried out
Vein open done and stat medication given
All the ordered investigation send
Monitored vital sing
Maintained intake and output chart
Frequently assessed the patient’s condition
Monitored Weight
1
nd
day of admission( 2068/07/14)
Patient’s general condition was not improved than yesterday.
Injection vit k added
Dose of tablet lasilactone changed from ½ tab to one tab
Fluid restriction <1000ml /day
Low salt diet and egg white BD ordered
Arrange and transfuse 1 pint of FFP
B.P=100/60 mm of hg, R.R=22/min,
Pulse=96/min, Temp.=98ºf weight: 37kg abdominal girth = 31”
Intake=1050ml output= 1000ml
Date :- 2068/07/ 13
Admission day
A patient was admitted in male medical ward from OPD with history of
abdominal distention , bilateral pedal edema , mild shortness of breathing and
loss of appetite .
On admission patient’s vitals sign were:
B.P=110/60 mm of hg, R.R=22/min,
Pulse=98/min, Temp.=98ºf weight: 37kg
Patient’s general condition was ill looking.
Mild to moderate shortness of breathing was noticed.
USG abdomen and all base line investigation was ordered
MAJOR NURSING INTERVENTION
Admission procedure carried out
Vein open done and stat medication given
All the ordered investigation send
Monitored vital sing
Maintained intake and output chart
Frequently assessed the patient’s condition
Monitored Weight
1
nd
day of admission( 2068/07/14)
Patient’s general condition was not improved than yesterday.
Injection vit k added
Dose of tablet lasilactone changed from ½ tab to one tab
Fluid restriction <1000ml /day
Low salt diet and egg white BD ordered
Arrange and transfuse 1 pint of FFP
B.P=100/60 mm of hg, R.R=22/min,
Pulse=96/min, Temp.=98ºf weight: 37kg abdominal girth = 31”
Intake=1050ml output= 1000ml
MAJOR NURSING INTERVENTION
Assessed in all morning care
Monitored of vital sign regularly
Attended doctor’s round.
Hair comb done
Nail care given
I/V site changed
Daily weight and abdominal girth taken and recorded .
Detail history was done.
2
nd
day of admission( 2068/07/15)
Patient’s general condition was as same as yesterday.
Serum creatinine and platelet test order for tomorrow.
Fluid restriction <1000ml /day
Low salt diet and egg white BD ordered
Arrange and transfuse 1 fresh whole blood.
B.P=120/70 mm of hg, R.R=20/min,
Pulse=96/min, Temp.=98.8ºf weight: 37.5kg abdominal girth = 32”
Intake=1050ml output= 9050ml
MAJOR NURSING INTERVENTION
Assessed in all morning care
Monitored of vital sign regularly
Attended doctor’s round.
Hair comb done
Daily weight and abdominal girth taken and recorded .
Encouraged for intake of food
Head to toe physical examination was done.
3
nd
day of admission( 2068/07/16)
Patient’s general condition was worse than yesterday.
Assessed in all morning care
Monitored of vital sign regularly
Attended doctor’s round.
Hair comb done
Nail care given
I/V site changed
Daily weight and abdominal girth taken and recorded .
Detail history was done.
2
nd
day of admission( 2068/07/15)
Patient’s general condition was as same as yesterday.
Serum creatinine and platelet test order for tomorrow.
Fluid restriction <1000ml /day
Low salt diet and egg white BD ordered
Arrange and transfuse 1 fresh whole blood.
B.P=120/70 mm of hg, R.R=20/min,
Pulse=96/min, Temp.=98.8ºf weight: 37.5kg abdominal girth = 32”
Intake=1050ml output= 9050ml
MAJOR NURSING INTERVENTION
Assessed in all morning care
Monitored of vital sign regularly
Attended doctor’s round.
Hair comb done
Daily weight and abdominal girth taken and recorded .
Encouraged for intake of food
Head to toe physical examination was done.
3
nd
day of admission( 2068/07/16)
Patient’s general condition was worse than yesterday.
Complain of shortness of breathing and abdominal discomfort .
Serum creatinine and platelet test was send and report collected (creatinine
=1.7mg/dl , platelet 67,000 mm3)
1pint fresh whole blood was transfused.
B.P=140/90 mm of hg, R.R=22/min,
Pulse=96/min, Temp.=97ºf weight: 37.5kg abdominal girth = 33.2”
Intake=800ml output= 700ml Sp02 =92% without o2.
MAJOR NURSING INTERVENTION
Assessed in all morning care
Monitored of vital sign regularly
Attended doctor’s round.
Hair comb done
Daily weight and abdominal girth taken and recorded .
Encouraged for intake of food
High fowlers’ position was maintained
4
nd
day of admission( 2068/07/16)
Patient’s general condition was worse than yesterday.
Complain of shortness of breathing and abdominal discomfort more severe
than yesterday.
Patient was drowsy and lethargic
Nothing was taken from yesterday evening
Patient party asked for discharge
Patient was discharged on request.
B.P=130/90 mm of hg, R.R=22/min,
Pulse=100/min, Temp.=99ºf weight: 38kg abdominal girth = 34”
Intake=600ml output= 500ml Sp02 =90% without o2.
MAJOR NURSING INTERVENTIONS
Assessed in all morning care
Attended doctor round .
Removed the i/v cannula
Performed all discharge procedure
Provided discharge teaching on the following topics:
Serum creatinine and platelet test was send and report collected (creatinine
=1.7mg/dl , platelet 67,000 mm3)
1pint fresh whole blood was transfused.
B.P=140/90 mm of hg, R.R=22/min,
Pulse=96/min, Temp.=97ºf weight: 37.5kg abdominal girth = 33.2”
Intake=800ml output= 700ml Sp02 =92% without o2.
MAJOR NURSING INTERVENTION
Assessed in all morning care
Monitored of vital sign regularly
Attended doctor’s round.
Hair comb done
Daily weight and abdominal girth taken and recorded .
Encouraged for intake of food
High fowlers’ position was maintained
4
nd
day of admission( 2068/07/16)
Patient’s general condition was worse than yesterday.
Complain of shortness of breathing and abdominal discomfort more severe
than yesterday.
Patient was drowsy and lethargic
Nothing was taken from yesterday evening
Patient party asked for discharge
Patient was discharged on request.
B.P=130/90 mm of hg, R.R=22/min,
Pulse=100/min, Temp.=99ºf weight: 38kg abdominal girth = 34”
Intake=600ml output= 500ml Sp02 =90% without o2.
MAJOR NURSING INTERVENTIONS
Assessed in all morning care
Attended doctor round .
Removed the i/v cannula
Performed all discharge procedure
Provided discharge teaching on the following topics:
Medication
Diet
Follow up
Rest and sleep
Regular check up
Prevention of recurrence of disease etc.
SPECIAL GAGETS USED IN MY PATIENT
Sphygmomanometer
Stethoscope
ECG monitoring
U.S G machine.
Knee hammer.
Thermometer
Pulse oxymeter.
Discharge medication
Tab Lasilactone 1 tab Po OD x 7 days
Tab Pantium 40 mg Po OD x 10 days
Tab Tone 100 PO BD x 7 days
Tab Usoliv 300mg PO BD x 7 days
Inj. Vitamin K 1 amp I/V OD x 3 Days
Fluid restriction < 1000 ml /Day
Low salt diet
Egg white BD
Follow up after 1 week and sos.
Learned from the Experience
◦ Identified the complete health need of old age .
◦ Provide comprehensive nursing care to the patient having cirrhosis of
liver
◦ Provide the opportunity for in-depth study of disease condition
◦ Develop competency in handling such disease condition
Diet
Follow up
Rest and sleep
Regular check up
Prevention of recurrence of disease etc.
SPECIAL GAGETS USED IN MY PATIENT
Sphygmomanometer
Stethoscope
ECG monitoring
U.S G machine.
Knee hammer.
Thermometer
Pulse oxymeter.
Discharge medication
Tab Lasilactone 1 tab Po OD x 7 days
Tab Pantium 40 mg Po OD x 10 days
Tab Tone 100 PO BD x 7 days
Tab Usoliv 300mg PO BD x 7 days
Inj. Vitamin K 1 amp I/V OD x 3 Days
Fluid restriction < 1000 ml /Day
Low salt diet
Egg white BD
Follow up after 1 week and sos.
Learned from the Experience
◦ Identified the complete health need of old age .
◦ Provide comprehensive nursing care to the patient having cirrhosis of
liver
◦ Provide the opportunity for in-depth study of disease condition
◦ Develop competency in handling such disease condition
◦ Provide the opportunity to o apply the Nursing theory in real
situation.
◦ Identified the evaluate the educational need of the patient and
patient family.
SIGNIFICANCE FINDINGS AND SUMMARY
chief complain on Admission (2068/07/13)
Abdominal distention since 15-16 days
Bilateral pedal swelling since 10-12 days
Moderate shortness of breathing since 5-7 days
Loss of appetite since 15-16 days
On Physical examinations
Abdominal distention +
Fluid thrill +
Swelling of face +
Hepatomegaly +
Icterus +
Significant Investigations
SGOT/AST : 187.0 U/L
AGPT/ALT: 88.0 U/L(˂40.0 U/L)
Albumin : 3.4 gm/dl (3.5-5.5 gm/dl)
Bilirubin Total: 2.2mg/dl (0.4-1.0 md/dl)
Prothombin time: 23.3 sec( 14-16 sec)
INR : 1.8 ( o.8-1.2)
Creatinine : 2.0 mg /dl
Haemoglobin: 7.8 gm/dl
WBC : 11,600 Mm3
Platelets : 61,000 Mm3
situation.
◦ Identified the evaluate the educational need of the patient and
patient family.
SIGNIFICANCE FINDINGS AND SUMMARY
chief complain on Admission (2068/07/13)
Abdominal distention since 15-16 days
Bilateral pedal swelling since 10-12 days
Moderate shortness of breathing since 5-7 days
Loss of appetite since 15-16 days
On Physical examinations
Abdominal distention +
Fluid thrill +
Swelling of face +
Hepatomegaly +
Icterus +
Significant Investigations
SGOT/AST : 187.0 U/L
AGPT/ALT: 88.0 U/L(˂40.0 U/L)
Albumin : 3.4 gm/dl (3.5-5.5 gm/dl)
Bilirubin Total: 2.2mg/dl (0.4-1.0 md/dl)
Prothombin time: 23.3 sec( 14-16 sec)
INR : 1.8 ( o.8-1.2)
Creatinine : 2.0 mg /dl
Haemoglobin: 7.8 gm/dl
WBC : 11,600 Mm3
Platelets : 61,000 Mm3
Liver ultrasound
impression: s/o cirrhosis of Liver, Moderate Ascites
Medical Management
: fluid restriction
Transfusion of 2 pint FFP
Vit K and inj. polybion supplementary
diuretic drugs (lasilaction)
Daily weight and abdominal girth monitoring
Prognosis of patient
initially improved than detoriation of condition
Discharged on request on 2068/07/17
impression: s/o cirrhosis of Liver, Moderate Ascites
Medical Management
: fluid restriction
Transfusion of 2 pint FFP
Vit K and inj. polybion supplementary
diuretic drugs (lasilaction)
Daily weight and abdominal girth monitoring
Prognosis of patient
initially improved than detoriation of condition
Discharged on request on 2068/07/17
PATHOPHYSIOLOGY OF CIRRHOSIS OF LIVER
Liver insult, Alcohol ingestion, viral hepatitis, exposure to toxin,
Hepatocyte damage
Liver inflammation
WBC, fever, anorexia,
Pain, , nausea, vomiting fatigue,
Alteration in blood and lymph flow
Liver necrosis
Liver fibrosis and
scarring
Portal hypertension
Acites, Edema, spleenomegaly
Anaemia, thrombocytopenia,
leukopenia
Varices
Esophageal varices, superficial
abdominal vertices (caput medusa)
Hemorrhoids
Decreased bilirubin
metabolism/biliary tree
damage/obstruction
Hyperbilirubinemia
Jaundice
Decreased bile in
gastrointestinal tract
Light colored stool
Increased urobilinogen
Dark urine
Decreased vit. K
absorption
Bleeding tendency
Hormone metabolism
Androgen &estrogen
Gynaecomastia
Loss of body
hair
Menstrual
dysfunction
Spider angioma
Palmar
erythemia
ADH & Aldestrone
Edema
Metabolism of protein
Decreased Plasma protein
Ascites ,edema
Carbohydrate & Fat metabolism
Hypoglycemia
Malnutrition
Liver failure
Inability to metabolize ammonia to urea
Hepatic encephalopathy
Hepatic coma
Death
Increased serum ammonia, alteration in
sleep, asterixis, respiratory acidosis, foul
breath
Liver insult, Alcohol ingestion, viral hepatitis, exposure to toxin,
Hepatocyte damage
Liver inflammation
WBC, fever, anorexia,
Pain, , nausea, vomiting fatigue,
Alteration in blood and lymph flow
Liver necrosis
Liver fibrosis and
scarring
Portal hypertension
Acites, Edema, spleenomegaly
Anaemia, thrombocytopenia,
leukopenia
Varices
Esophageal varices, superficial
abdominal vertices (caput medusa)
Hemorrhoids
Decreased bilirubin
metabolism/biliary tree
damage/obstruction
Hyperbilirubinemia
Jaundice
Decreased bile in
gastrointestinal tract
Light colored stool
Increased urobilinogen
Dark urine
Decreased vit. K
absorption
Bleeding tendency
Hormone metabolism
Androgen &estrogen
Gynaecomastia
Loss of body
hair
Menstrual
dysfunction
Spider angioma
Palmar
erythemia
ADH & Aldestrone
Edema
Metabolism of protein
Decreased Plasma protein
Ascites ,edema
Carbohydrate & Fat metabolism
Hypoglycemia
Malnutrition
Liver failure
Inability to metabolize ammonia to urea
Hepatic encephalopathy
Hepatic coma
Death
Increased serum ammonia, alteration in
sleep, asterixis, respiratory acidosis, foul
breath
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