Objectives General This case presentation was formulated to understand thoroughly the disease process of the client and

the nursing interventions that could be utilized to provide the most efficient quality of care. The case also aims to make the readers aware about the disease and how it greatly affects the well-being of an individual. By thorough assessment and nursing skills, this case will give a comprehensive knowledge to every individual to be able to promote health and prevent the occurrence of the disease. Specific To define thoroughly the underlying disease process of Liver Cirrhosis, its etiology, risk factors and signs and symptoms. To distinguish the atypical changes that happen to the client in the development of the disease in line with the appropriate nursing interventions that should be provided. To proficiently execute the appropriate nursing interventions to the urgent needs of the client taking into consideration the magnitude and scope of the disease. To spontaneously adhere with the standards of quality patient care and accurately give health teachings to the client and her family to alleviate the signs and symptoms brought about by the disease. To exhibit the passion in responding to the vital needs of the client as she goes to the course of the disease. To help the client and the relatives cope with the disease by being an attentive listener and good advocate of health.

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Introduction Liver Cirrhosis, a consequence of chronic liver disease, is chosen to be presented in this Grand Case Presentation due to its interesting insights, its interesting outcome, and several complications that the group could interfere with. This can serve the group in enhancing critical thinking and knowledge while practicing proper care and proper interaction with the patient. Furthermore, it was chosen due to the knowledge that the group can imply in regarding with this case and for application of what we have learned from the past lectures. The groups motivation and willingness in pursuing this case served as an enhancement in practicing proper management within this condition. Cirrhosis, from the greek word kirros which means tawny which is the color of the diseased liver is a consequence of chronic liver disease characterized by replacement of liver tissue by fibrosis, scar tissue and regenerative nodules or lumps. It occurs as a result of process in which damaged tissue is regenerated which then leads to loss of liver function. Cirrhosis is an abnormal liver condition in which there is irreversible scarring of the liver. The main causes are sustained excessive alcohol consumption, viralhepatitis B and C, and fatty liver disease; however, there are many other possible causes. For cirrhosis to develop in long- term, damage to the liver continuously needs to occur overtime. When the replacement of scar tissue destroys a healthy liver tissue, the condition becomes more serious as it starts to block the flow of blood through the liver. Cirrhosis is a progressive disease which develops slowly over years until eventually it would stop the function of the liver which then causes liver failure. As liver function decreases, fewer proteins such as albumin are produced resulting in fluid accumulation in the legs (edema) or abdomen (ascites). Individuals with cirrhosis may bleed and bruise easily due to a decrease in proteins required for blood clotting. Some people may even experience intense itching due to products that are deposited in the skin. The liver has many essential functions to the body. Some of the functions are to detoxify harmful substances in the body, purifies the blood and manufactures vital nutrients. If cirrhosis is mild, the liver can repair and continue its functioning properly. But if the cirrhosis became more advanced and more scar tissue forms in the liver, the damage becomes irreparable. The liver tissue is then replaced by fibrous scar tissue as well as regenerative nodules or the lumps that appear as a consequence process in which the damaged tissue is regenerated. In the later stages of cirrhosis, jaundice occurs and gallstones are more common because insufficient levels of bile reach the gallbladder. A cirrhotic liver no longer removes toxins effectively leading to toxin accumulation in the blood, which in turn can impair mental function and lead to personality changes and possibly coma. Early signs of toxin accumulation in the brain may include neglect of personal appearance, unresponsiveness, forgetfulness, concentrationproblems or changes in sleeping habits. Because the normal cleansing process is impaired by cirrhosis, drugs are not properly filtered resulting in an increased sensitivity to drugs and their side-effects. Normally, blood from the intestines and spleen is pumped to the liver through the portal vein. However, cirrhosis blocks the normal flow of blood through the liver. This can lead to swelling of the liver and potentially the spleen. Blood from the intestines, is then forced to find a new way around the liver through new vessels. Some of these new blood vessels called "varices" which form primarily in the stomach and esophagus become quite large. These

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varicesmay rupture due to high blood pressure (portal hypertension) and thin vessel walls, causing bleeding in the upper stomach or esophagus. The most common cause of cirrhosis is undoubtedly the repeated and excessive consumption of alcohol. Long term consumption of alcohol leads to permanent destruction of the liver cells and causes scarring of the liver tissue called cirrhosis. Obesity and diabetes is another risk factor that can cause excess fat accumulation in the liver which then leads to fatty liver that can further lead to cirrhosis. Cirrhosis also caused by hereditary disorder like cystic fibrosis and glycogen storage disorder. Viral infection most commonly Hepatitis B, C and D can also cause cirrhosis. Disorders in the bile ducts due to blockage by stones, tumours or inflammation in adults can also lead to primary biliary cirrhosis which accumulates in the liver. Another cause that is worth mentioning is right heart failure which then causes fluid to go back to the liver. Excess of iron, also known as Hemochromatosis, and Wilsons disease, which causes abnormal deposition of copper, is also a major cause of liver cirrhosis. Reactions to prescription drugs and parasitic infections like schistosomiasis can also cause liver cirrhosis. As the disease progresses, general signs and symptoms may appear. Some of the earlier sign and symptoms are loss of appetite, nausea, weight loss, fatigue, weakness, and exhaustion. One of the most common sign and symptoms is ascites or when the abdomen fills up with fluid giving the patient a large tummy. Another most common symptom of cirrhosis is Jaundice or yellowing of the skin, whites of the eyes and tongue. Accelerated heartbeat, bleeding gums, and altered personality may also be present. Body and upper arms loses its mass while the body finds it harder to process and drugs are also harder to be processed. Confusion, dizziness and memory problems may also occur. The urine also darkened in color while the stools are pale or clay colored.Itchiness of the skin may also be present due to the products that are deposited in the skin. The exact prevalence of cirrhosis is unknown, but it has been estimated, through autopsies, to be between 5 and 10 percent. Incidence of cirrhosis varies by country and region, and reflects relative contributions from different risk factors. In countries where alcohol consumption is common, alcoholic cirrhosis is the major contributor to the overall prevalence of cirrhosis. In countries with low alcohol consumption, hepatotropic viruses (hepatitis B and C) are the major contributors. An estimated 25,000 individuals in the United States died from liver disease in 1998, making liver disease the tenth leading cause of death. For individuals between 45 and 64 years of age, chronic liver disease had an associated mortality rate of 19.6 per 100,000 persons and was the seventh leading cause of death.Cirrhosis of the liver is an important cause of illness and death. In 2000 it killed more men than Parkinson's disease and more women than cancer of the cervix.Large rises in death rates from chronic liver disease and cirrhosis have occurred in most age groups. In 45-54 year olds, there has been a greater than 4-fold increase amongst men since the early 1970s and a 3-fold increase in women. In 35-44 year olds, the rise has been even larger: an 8-fold increase in men and approaching a 7-fold increase in women. The rise in deaths from cirrhosis amongst younger people is of particular concern where binge drinking patterns appear to be common. In 2000 cirrhosis accounted for nearly 500 deaths in men aged 25-44 years and nearly 300 deaths in women of this age group.There are many different causes of cirrhosis but it is often due to excess alcohol consumption. Another cause which is increasingly important is chronic viral hepatitis,

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especially hepatitis C. Alcohol consumption will increase the rate of progression of cirrhosis from whatever cause. Cirrhosis is most commonly caused by alcoholism, hepatitis B and C and fatty liver disease but it can also be caused by many different factors. Some cases are still unknown. Cirrhosis is the 11th most common cause of death in the United States and it is most common among people ages 45-75 years of age. Most cases are a result of alcoholism, biliary destruction, hepatitis, and number of metabolic conditions may stimulate the destruction process. The disease ranks as the 13th leading cause of death and has affected 126, 826 Filipinos in the Philippines in the year 2005. Locally, liver cirrhosis is the 17th leading cause of death.

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I.

Patients Profile A. Demographic Data Name : E.B.R. Age : 86 years old Gender : Female Nationality : Filipino Religion : Roman Catholic Date and Time of Admission : June 20, 2013 3:45:53 PM Clinical Impression : Liver Cirrhosis B. Chief Complaint Abdominal pain and diarrhea for 3 days prior to admission C. History of Present Illness According to the patient, she was experiencing abdominal pain and diarrhea for 3 days.
D. History of Past Illness Patient was diagnosed with Hepatitis A & B but it was cured.

E. History of Family Illness According to the clients husband, her wife has a family history of cancer. F. Social History Client EBR is currently living in a four floor house with good environment. Shes married and has one daughter who has now had own family. She lives with her husband and her daughters own family. Client doesnt have work for how many years and has been involved in playing mahjong. She worked as a teacher but her husband insisted to quit to her job. She loves playing mahjong and at the same time to go shopping. G. Allergies Client has no known allergies.

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Assessment GERIATRIC ASSESSMENT CRITERIA Posture and Gait NORMAL FINDINGS Relaxed and erect posture Coordinated movement Clean and neat ACTUAL FINDINGS Relaxed and has coordinated movement Clean and neat INTERPRETATION AND ANALYSIS Normal

Overall Hygiene and Grooming

Normal

SKIN Color Light to deep brown Yellowish extremities Patient has jaundice due to increase in bilirubin level Normal Normal Normal

Uniformity Moisture Turgor

Uniform in color Moisture in skin folds Skin intact and springs back

Skin is uniform Moist in skin folds Good skin turgor but has dry skin

HAIR Hair Evenness Hair Thickness Texture and Oiliness Color Scalp Evenly distributed Thin hair Silky and resilient Dark brown to black Shiny, smooth and without lesions, lumps and masses Evenly distributed Thin hair Smooth hair Black No lesions, lumps and masses noted. Scalp is smooth. Normal Normal Normal Normal Normal

NAILS Curvature Convex curvature, angle of nail plate about 160 degree Smooth Prompt color return (1-2 seconds) Convex curvature, angle of nail plate about 160 degree Smooth Capillary refill is less than 2 seconds Normal

Texture Blanch Test

Normal Normal

EYES Eyebrows Evenly distributed Evenly distributed Normal

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Eyelashes Upper lids Lower eyelids Bulbar conjunctiva Color Pupil

Even and outward No discharge or discoloration Closes symmetrically Transparent, capillary evident No discoloration Equally round, size and color (2-3cm)

Even and outward No discharge or discoloration Closes symmetrically Transparent, capillary evident No discoloration Pupils are equally round, reactive to light and accommodation

Normal Normal Normal Normal Normal Normal

EARS The ears have the same color with no lesions. There were no deformities, or a foreign body found and is positioned in proportion to the head. NOSE The nose is located midline of the face. There are no thick mucus secretions found. There are no deformities, bleeding or masses found.

MOUTH AND THROAT The gums are pink, moist and no swelling is found. There are no tooth decay and plaque found. There were no problems in the throat.

EDEMA No edema was present.

MUSCULOSKELETAL Patient has a generalized body weakness due to medical condition. Patients Lovett scale is 2 which indicate that there is a complete range of motion without gravity.

RESPIRATORY The patient has clear breath sounds upon auscultation. However, the patient is experiencing difficulty of breathing sometimes especially when patient rises up from bed.

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CARDIOVASCULAR No abnormal pulsations/ vibrations were palpated.

ADBOMEN Patient has an abdominal girth of 93 cm and is firm when palpated.

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Vital Signs Date: June 26, 2013

CRITERIA Height Weight Temperature Pulse Rate Respiratory Rate Blood Pressure

ACTUAL FINDINGS 5 feet 46kg 36.7 C 75 beats per minute 20 breaths per minute 120/60

INTERPRETATION AND ANALYSIS Normal Normal since the BMI of the patient is 20 Normal Normal Normal Normal

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Gordons Functional Health Pattern Before Hospitalization Subjective Ok namansiya, hindinamanyansakitineh,bihira lang. Nagsisigarilyosiyadatiperotumigilnaisya almost a year na din as verbalized by the patients husband. During Hospitalization A. Health Perception - Health Management Pattern Subjective Nungbagosiyadalhin, nagtataesiyatapossumakitna din angtiyan kaya dinalananamindito as verbalized by the patients husband.

Objective Patient EBR perceives her health good but she cant perform now her usual activities without the assistance of her relatives.

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Before Hospitalization Subjective Malakas sya kumain. Ganun naman pag lalaki eh diba."

During Hospitalization B. Nutritional and Metabolic Pattern Subjective Ngayongnaospitalako, nabawasanyungtimbangko. Tatlongbesesakongumiinomngtubigsaisangar aw.

Objective Patient EBR has a fair skin complexion with normal texture. Capillary refill time is normal, immediate return of color less than 2 seconds. The patient has an intact IV access of PNSS 1L x 20cc/hr.

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Before Hospitalization Subjective Araw-arawsiyangdumudumi, tuwingumaga, lagiyan. Ok namanangpag-ihiniya, walanamansiyangcinocomplainkapagumiihi siya as verbalized by the patients husband. C. Elimination Pattern Subjective

During Hospitalization Objective Patient EBR has no problems in voiding. He voids frequently and defecates every morning. Bowel sounds are normal upon auscultation.

Nakakaihi pa rinnamansiya as verbalized by the patients husband. Yung duminiya, kulay yellow na may pagkabrown as verbalized by the patients relative.

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Before Hospitalization Subjective Naku! Puromajongangbuhayniyan. Monday to Friday lagingnasamajongyan o kaya nasa mall, nagshoshoppingkasamayungkatulongna min Hindi siyamahiligmagluto o kungano man, bastanasamajonglangtalagasiya as verbalized by the patients husband.

During Hospitalization D. Activity and Exercise Pattern Subjective Nanghihinadawsiyangayon eh tapossumasakit pa yungtiyan kaya gusto niyangmagpahinga as verbalized by the patients husband.

Objective

Patient EBD was only in bed, experiencing body weakness and cannot perform her some usual activities. The patients functional level was assessed based on his ability to perform activities. - Feeding: Level 2 (Requires assistance from others) - Toileting: Level 2 - Dressing: Level 2

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Before Hospitalization Subjective Napansin ko nga na mas matagal yung oras ng tulog nya kesa sa gising sya kung ikukumpara sa dati kaya pinacheck-up na rin naming sya dito, as verbalized by the clients wife. E. Sleep Rest Pattern Subjective

During Hospitalization Objective Patient EBR has a disturbed sleeping pattern because she is experiencing pain on her right upper quadrant.

Puro pahinga naman sya dito. Kain, tulog tapos nuod ng tv. Bibihira mo makausap, medyo iritable minsan e, as verbalized by the clients wife.

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Before Hospitalization Subjective Naku! Malinaw pa angmataniyan, hindisiyagumagamitngsalamin. Wala din siyangproblemasapagdinig, hindinamansiyagumagamitng hearing aid as verbalized by the patients husband.

During Hospitalization F. Cognitive Perceptual Pattern Subjective Ganun pa din naman. Wala pa din siyangproblemasapandinig o samataniya. Masakit pa rinangtiyanko eh as verbalized by the patient.

Objective

The patient is oriented to time, person and place. Her visual acuity, auditory and speech are not affected. She experiences an uncomfortable pain on his right upper quadrant with a scale of 7/10.

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Before Hospitalization Subjective Ok namansiyasakin, patisaanak naming lalonasamgaaponiya Minsannagbobondingnaman kami as verbalized by the patients husband.

During Hospitalization G. Roles Relationship Pattern Subjective Pinapasyalannamansiyangmgaaponiyataposminsanyungan ak naming angnagbabantaysaknya ditto taposminsanako as verbalized by the patients husband.

Objective Patient EBR has a good relationship with her daughter, siblings and husband.

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Before Hospitalization Subjective Hindi namanyannaiistresskasipuromajongngalangsiya. Peromahiligyan making ng music as verbalized by the patients husband.

During Hospitalization H. Coping Stress Tolerance Pattern Subjective Hindi nasiyanakakapagmajong as verbalized by the patients husband.

Objective

The patient and his relatives were advised to avoid any stressful matters that will aggravate his condition.

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Before Hospitalization I. Subjective Linggo-linngosiyanagsisimbasa Catholic Church. Oo, importantesakanyaang religion kaya ngatalagalagipagtuwinglinggonagsisimbas iya. Kahitmatanda nay an, hindisiyananiniwalasamga herbal medicines as verbalized by the patients husband.

During Hospitalization Value Belief Pattern Subjective

Objective

Nagdadasalnamansiya as verbalized by the patients husband.

Patient EBR is a practicing roman catholic and attends mass every Sunday. She doesnt believe in traditional medicines such as herbal remedies.

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Before Hospitalization Subjective Ok naman. Satisfied namanakokunganoyungmeronakon gayon.

During Hospitalization J. Self Perception Self Concept Pattern Subjective Hindi kotalagaalam kung bakitnangyariitosapaakoperohindikoito gusto. Nahihiyaakokasi may sugatakosakanangpaa at bintiko. Dahilnangyariitosa akin, parang mas nagingmaingatnaakosamgagawainkotapos mas nabibigyanghalagakonayungsarilikolalonayungkalus uganko.

Objective Patient EBR is satisfied about her life. When she had the disease, she cant do her usual hobbies.

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Before Hospitalization Subjective K. Sexuality Reproductive Pattern Subjective

During Hospitalization Objective Patient EBR is still living with her husband and they are married for 57 years and had one daughter.

57 years nakamingkasaltaposisangbabaelangangnaginganak naming. 29 years old siyanungmabuntistapos 27 namanako. Magkatabi pa rin kami niyangmatulogperomagkatalikurankasibakamahawaak osakanyaas verbalized by the patients husband.

Nanditolangakolagiparasakanya as verbalized by the patients husband.

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Anatomy and Physiology THE LIVER

Liver is the largest gland in the body, a spongy mass of wedge-shaped lobes that has many metabolic and secretory functions. The liver secretes bile, a digestive fluid; metabolizes proteins, carbohydrates, and fats; stores glycogen, vitamins, and other substances; synthesizes blood-clotting factors; removes wastes and toxic matter from the blood; regulates blood volume; and destroys old red blood cells. Microscopic structure of the liver Liver tissue consists of a mass of cells tunneled through with bile ducts and blood vessels. Hepatic cells make up about 60 percent of the tissue and perform more metabolic functions than any other group of cells in the body. A second group of cells, called Kupffer cells, line the smallest channels of the liver's vascular system and play a role in blood formation, antibody production, and ingestion of foreign particles and cellular debris. Each day the liver secretes about 800 to 1,000 ml (about 1 quart) of bile, which contains bile salts needed for the digestion of fats in the diet. Bile is also the medium for excretion of certain metabolic waste products, drugs, and toxic substances. From the liver a duct system carries bile to the common bile duct, which empties into the duodenum of the small intestine and which connects with the gallbladder, where it is concentrated and stored. The presence of fat in the duodenum stimulates the flow of bile out of the gallbladder and into the small intestine. Senescent (worn-out) red blood cells are destroyed in the

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liver, spleen, and bone marrow. A pigment, bilirubin, formed in the process of hemoglobin breakdown, is released into the bile, creating its characteristic greenish orange colour, and is excreted from the body through the intestine. The liver cells synthesize a number of enzymes. As blood flows through the liver, both from the portal vein and from the hepatic artery, the cells and enzymes are filtered. Nutrients entering the liver from the intestine are modified into forms that are usable by the body cells or are stored for future use. Fats are converted into fatty acids and then into carbohydrates or ketone bodies and transported by the blood to the tissues, where they are further metabolized. Sugars are converted into glycogen, which remains stored in the liver until it is needed for energy production; it is then reconverted into glucose and released into the bloodstream. The liver manufactures blood serum proteins, including albumin and several clotting factors, and supplies them to the blood. The liver also metabolizes nitrogenous waste products and detoxifies poisonous substances, preparing them for elimination in the urine or feces. A common sign of impaired liver function is jaundice, a yellowness of the eyes and skin arising from excessive bilirubin in the blood. Jaundice can result from an abnormally high level of red blood cell destruction (hemolytic jaundice), defective uptake or transport of bilirubin by the hepatic cells (hepatocellular jaundice), or a blockage in the bile duct system (obstructive jaundice). Failure of hepatic cells to function can result from hepatitis, cirrhosis, tumours, vascular obstruction, or poisoning. Symptoms may include weakness, low blood pressure, easy bruising and bleeding, tremor, and accumulation of fluid in the abdomen. Blood tests can reveal abnormal levels of bilirubin, cholesterol, serum proteins, urea, ammonia, and various enzymes. A specific diagnosis of a liver problem can be established by performing a needle biopsy. The liver is subject to a variety of other disorders and diseases. Abscesses can be caused by acute appendicitis; those occurring in the bile ducts may result from gallstones or may follow surgery. The parasite that causes amebic dysentery in the tropics can produce liver abscesses as well. Various other parasites prevalent in different parts of the world also infect the liver. Liver cancer is common, occurring mostly as secondary tumours originating elsewhere in the body. Glycogen-storage diseases, a group of hereditary disorders, generate a buildup of glycogen in the liver and an insufficient supply of glucose in the blood. Certain drugs may damage the liver, producing jaundice.

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Pathophysiology
Non-modifiable Factors: Age: 86 years old Gender: Female Family History Cancer Post-hepatic infection (Hepatitis A and B virus) Modifiable Factors: Diet: High in Fat Smoking for 1 year Sedentary Lifestyle (Plays Mahjong all the time)

Hepatocyte injury in the liver

Elevated Liver enzymes (SGOT/AST: 53 u/L)

Inflammation of the liver

Right Upper Quadrant Pain VAS: 7/10

Inflammation obstructs hepatic flow

Liver necrosis

Liver fibrosis (scarring)

Liver may become so seriously scarred = Liver cirrhosis

Elevation of both conjugated and unconjugated bilirubin in the blood

Decreased synthesis of albumin

Portal Hypertension

Increased Conjugated Bilirubin (1.16 mg/dL)

Decreased plasma osmotic pressure Decreased Albumin: 2.60 g/dl (6/20)

Increased hydrostatic pressure in portal circulation

Splenomegaly

Jaundice (Skin)

Fluid shift out of portal circulation into peritoneal cavity

Anemia (9.5 g/dL) Leukopenia (3, 700 mm3) Decreased platelet count (139,000/mm3)

Bile salts in the blood backs up causing irritation

Pruritus

Ascites (Abdominal girth: 93 cm)

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Legend: - Pathophysiology - Signs and symptoms - Laboratory and Diagnostic Exams

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Course in the Ward 6/25/13 At I: 00 PM, doctor ordered to discontinue Lasix infusion. An IVF PNSS 1 L to run for 20 cc/hr was ordered at 7:00 PM and doctor suggested to startErceflora thrice a day. At 8:30 PM, there was no objection to undergo oral chemo for GI serum. Doctor also suggested to increase Spironolactone 100 mg 1 tab once a day. 6/26/13 9:30 AM Carry out Erceflora TID include 2 scoops of impact whey in AM and PM. Increase Aldactone 100 mg once a day ALK Phosphate 183 (299) TPAG 5.20 2/3.20 Na 139 K 3.9 (3.6) Monitored vital signs every hours Diet is low salt, low fat Measured abdominal girth

11:00 AM Patient was asleep, comfortable not in distress (+) report of abdominal discomfort No chest pain, no recurrent vomiting, a febrile Continue meds, awaits GI clearance Decrease Albumin 2.0

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I. DIAGNOSTIC PROCEDURE AND LABORATORY EXAMINATION

Hepa A, B, C Serum June 15, 2013 Hepa B envelope antigen Hepa B Surface Antigen IgM Antibody to Hepa B Core Antigen Antibody to Hepa B envelope Antigen Antibody to Hepa B Surface Antigen Result Non Reactive Non Reactive Reactive Reactive Interpretation This indicates that the person is not infected with the Hepatitis B virus. Indicates recent, acute infection of less than 6 months duration. This indicates acute infection or chronic infection hepatitis B virus is present can spread the virus to other This indicates acute infection or chronic infection hepatitis B virus is present can spread the virus to other Indicate that there is no recent infection with hepatitis A virus. the test indicates that the persons body produces the type of antibody (called IgG) that recognizes (aka, "anti") hepatitis A virus. It also indicates that immune protection against future hepatitis A infection is seen. Indicates that the person has not been infected with the hepatitis C virus, and further testing for hepatitis C usually is not needed.

Reactive

Igm Antibody to Hepa A Virus IgG Antibody to Hepa A Virus

Non Reactive Reactive

Antibody to Hepa C Virus

Non Reactive

Anti- HBs

43.81 mlV/mL

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Indicative of past Hepatitis B infection and clinical recovery. Indicative of Immunity or clinical recovery from Hepatitis A. Negative Hepa C.

Complete Blood Count June 20, 2013 Hemoglobin Hematocrit RBC Count WBC Count Differential Count Neutrophil Lymphocyte Eosinophil Monocyte Platelet MCV MCH MCHC Result 12.3 g/dL 35.3% 3.86mil/ mm3 3,790 mm3 Normal Value 11.6-15.5 36.0-47.0 4.20-5.40 4800-10800 Interpretation Normal. Indicates anemia, can be due to bleeding, inadequate red blood cell production or a hemolytic process. Indicates of certain health problems, including anemia, blood loss, or malnutrition. Indicates a bacterial infection.

67% 23% 3% 7% 153,00/m m3 92fl 32pg 35%

40-74 19-48 0-7 3-9 150,000-40,000 82-98 28-33 32-38

Normal. Normal. Normal. Normal. Normal. Normal. Normal. Normal.

June 23, 2013 Hemoglobin Hematocrit RBC Count WBC Count Result 11.1g/dL 33.1% 3.58mil/ mm3 3,880mm Normal Value 11.6-15.5 36.0-47.0 4.20-5.40 4800-10800 Interpretation Indicates Polycythemia vera a blood disorder in which your bone marrow makes too many red blood cells. Indicates anemia, can be due to bleeding inadequate red blood cell production or a hemolytic process. Indicates of certain health problems, including anemia, blood loss, or malnutrition. Indicates a bacterial infection.

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3 Differential Count Neutrophil Lymphocyte Eosinophil Monocyte Platelet MCV MCH MCHC

63% 23% 4% 9% 140,000/ mm3 93 fl 31pg 34%

40-74 19-48 0-7 3-9 150,000-40,000 82-98 28-33 32-38

Normal. Normal. Normal. Normal. Normal. Normal. Normal. Normal.

June 25, 2013 Hemoglobin Hematocrit Result 11.3g/dL 33.6% Normal Value 11.6-15.5 36.0-47.0 Interpretation Indicates anemia. Indicates anemia, can be due to bleeding, inadequate red blood cell production or a hemolytic process (the red blood cells are being destroyed) Indicates certain health problems, including anemia, blood loss, or malnutrition Indicates a bacterial infection.

RBC Count WBC Count Differential Count Neutrophil Lymphocyte Eosinophil Monocyte Platelet MCV MCH MCHC

3.44mil/ mm3 4,100mm 3

4.20-5.40 4800-10800

66% 23% 3% 8% 130,000 98fl 33pg 34%

40-74 19-48 0-7 3-9 150,000-40,000 82-98 28-33 32-38

Normal. Normal. Normal. Normal. Normal. Normal. Normal. Normal.

June26,2013 Hemoglobin Hematocrit RBC Count WBC Count Differential Count Neutrophil Result 9.5g/dL 27.9% 2.88mil/ mm3 3,700mm 3 Normal Value 11.6-15.5 36.0-47.0 4.20-5.40 4800-10800 Interpretation Indicates anemia. Indicates anemia, can be due to bleeding inadequate red blood cell production or a hemolytic process. Indicates certain health problems, including anemia, blood loss, or malnutrition Indicates a bacterial Infection.

60%

40-74

Normal.

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Lymphocyte Eosinophil Monocyte Platelet MCV MCH MCHC

28% 3% 9% 139,000/ mm3 97fl 33pg 34%

19-48 0-7 3-9 150,000-40,000 82-98 28-33 32-38

Normal. Normal. Normal. Normal. Normal. Normal. Normal.

Blood June 20, 2013 BUN Creatinine SGPT/ALT SGOT/AST Total Bilirubin Conjugated Bilirubin Unconjugated Bilirubin Alkaline Phosphatase Total Protein Albumin Globulin Albumin/ Globulin ratio Sodium Potassium Result 22 mg/dL 1.08 mg/dL 67 u/L 111 u/L 1.66 mg/dL 1.12mg/dL 0.54mg/dL 299u/L 6.60 g/dL 2.60g/dL 4.00 0.7 Normal Value 7.18 0.60-1.20 12-78 15-37 6.40-8.20 0.00-0.20 0.00-0.80 50-136 6.40-8.20 3.40-5.00 2.3-3.5 1.5-2.5 Interpretation This indicates a decrease in muscle mass or too much fluid volume. Normal. Normal. Indicates liver disease Indicates different liver diseases and some non- liver disease. Indicates problems associated with the bile delivery system. Normal Indicates disease of the bile ducts, alone with some bone disorders. Normal. Indicates a sign of kidney disease or liver disease. Indicates chronic infections and or liver disease. Indicates Neoplasm, including multiple myeloma or metastatic disease, Infectious disease including AIDS, Intestinal disease, Liver disease, and or Renal disease Indicates to loss of too much sodium, too much water intake or retention, or to excess fluid accumulation in the body (edema). Normal.

134mmol/L 3.7mmol/L

136-145 3.5-5.1

June 26, 2013 Result Normal Value Interpretation

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BUN Creatinine SGPT/ALT SGOT/AST Total Bilirubin Conjugated Bilirubin Unconjugated Bilirubin Alkaline Phosphatase Total Protein Albumin Globulin Albumin/ Globulin ratio Sodium Potassium June23, 2013 Creatinine Sodium Potassium June21,2013 Creatinine

1.9 mg/dL 0.87 mg/dL 39 u/L 53 u/L 1.54mg/dL 1.16mg/dL 0.38mg/dL 183u/L 5.20g/dL 2.00g/dL 3.20 0.60

7.18 0.60-1.20 12-78 15-37 6.40-8.20 0.00-0.20 0.00-0.80 50-136 6.40-8.20 3.40-5.00 2.3-3.5 1.5-2.5

This indicates a decrease in muscle mass or too much fluid volume. Normal. Normal. Indicates Liver Disease. Indicates some liver diseases and non- liver disease. Indicates problems associated with the bile delivery system. Normal. Indicates disease of bile ducts, alone with some bone disorders. Indicates poor nutrition, liver disease, malabsorption, and or diarrhea. Indicates a sign of kidney disease or liver disease Normal. Indicates Neoplasm, including multiple myeloma or metastatic disease, Infectious disease including AIDS, Intestinal disease, Liver disease, and or Renal disease Normal. Normal.

139mmol/L 3.9mmol/L

136-145 3.5-5.1

Result 0.98 mg/dL 137mmol/L 3.6mmol/L

Normal Value 0.60-1.20 136-145 3.5-5.1

Interpretation This indicates overhydration. This indicates dehydration. Normal.

Result 1.06mg/dL

Normal Value 0.60-1.20

Interpretation This indicates overhydration.

June15, 2013 Alkaline Phosphatase SGPT/ALT SGOT/AST Result 246u/L 56 u/L 96 u/L Normal Value 50-136 12-78 15-37 Interpretation Indicates disease of bile ducts, alone with some bone disorders Normal. Indicates Liver Disease.

June 8, 2013 BUN Result 12 mg/dL Normal Value 7.18 Interpretation This indicates a decrease in muscle mass or too much fluid volume.

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Creatinine Sodium Potassium

0.93 mg/dL 139mmol/L 3.7mmol/L

0.60-1.20 136-145 3.5-5.1

This indicates overhydration. Normal. Normal.

Serum June 20,2013 Alpha FatoProtein (AFP) Result 1994,000mg/mL Normal Value <7.00 Interpretation This indicates in association with a variety of malignancies or benign diseases.

Prothrombine Time June 20, 2013 Ptt (Control) Result 12.6 secs Normal Value Interpretation Measures the time it takes your blood to clot. Helps in indicating any bleeding problems. Measures the time it takes your blood to clot. Helps in indicating any bleeding problems. Indicates that the blood is too thin

Ptt (Test)

14.6secs

11.9-14.2

Ptt (%) INR

60% 1.20

0.90-1.19

Stool June 21, 2013 Negative Clostodiumdifficile Antigen Test

Blood June 09, 2013 Fasting Blood Sugar Result 100mg/dL Normal 74-106 Interpretation Normal

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Drug Study Drug Generic Name: Ciprofloxacin Brand name: Quinosyn Drug class: Antibacterial Dose 50 mg PO BID Mechanism Of Action Inhibition of topoisomerase (DNA gyrase) enzymes, which inhibits relaxation of supercoiled DNA and promotes breakage of double stranded DNA. Indications And Contraindications Indications: Used to treat infections of the skin, lungs, airways, bones, and joints caused by susceptibl bacteria. Ciprofloxacin is also used to treat urinary infections caused by bacteria such as E. coli. It is also effective in treating infectious diarrheas caused by E. Coli, campylobacter jejuri, and Shigella bacteria. Contraindications: Ciprofloxacin iscontraindicated in persons with ahistory of hypersensitivity tociprofloxacin, anymember of thequinolone class of antimicrobial agents,or any of the productcomponents. Side Effects And Adverse Effects Side effects: Drowsiness, lightheadedness, stomach upset, diarrhea, nausea, vomiting, or headache may occur. Adverse effects: Nausea, Vomitting, Stomach pain, Heartburn, Diarrhea, hives, DOB, Fainting, Fever, Muscle pain, Extreme tiredness, restlessness, anxity. Nursing Considerations Instruct patient not to takeciprofloxacin with dairy products such as milk or yogurt, or with calcium-fortified juice. He may eator drink dairy products or calciumfortified juice witha regular meal, but do notuse them alone when takingciprofloxacin. They couldmake the medication lesseffective. Tell patient thatCiprofloxacin can causeside effects that may impair his thinking or reactions.Tell patient to be careful if he plans to drive or doanything that requires himto be awake and alert. Instruct patient to takeciprofloxacin with a fullglass of water (8 ounces). Instruct patient to avoidtaking antacids, vitamin or mineral supplements,sucralfate (Carafate), or didanosine (Videx) powder or chewable tablets within 6hours before or 2 hoursafter you take ciprofloxacin.These other medicines canmake ciprofloxacin muchless effective when taken atthe same time. Instruct patient to Stoptakingciprofloxacin andcall the doctor at once if hehas sudden pain, swelling,tenderness, stiffness, or movement problems in anyof your joints. Also instruct patient to rest his joint untilhe receive medical care or instructions.

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Drug Generic Name: Spironolactone Brand name: Aldactone Drug class: PotassiumSparing Diuretic

Dose 50 mg PO OD

Mechanism Of Action Spironolactone is a specific pharmacologic antagonist of aldosterone, acting primarily through competitive binding of receptors at the aldosteronedependent sodiumpotassium exchange site in the distal convoluted renal tubule. Spironolactone causes increased amounts of sodium and water to be excreted, while potassium is retained.

Indications And Contraindications Indications: Diagnosis and maintenance of primary hyperaldostero nism, Adjunctive therapy in edema associated with CHF, nephrotic syndrome, hatic cirrhosis when other therapies are inadequate. Treatment of hypokalemia or prevention of hypokalemia in patients who would be at high risk if hypokalemia occurred. Contraindications: Anuria, hyperkalemia, acute or progressive renal insufficiency, Addisons disease.

Side Effects And Adverse Effects Side effects: Drowsiness, lightheadedness, stomach upset, diarrhea, nausea, vomiting, or headache may occur.

Nursing Considerations Assess the patient with any allergies to spironolactone. Assess the patient in regarding hyperkalemia, renal disease and pregnancy. Assess the patients skin color, lesions, edema, and orientation. Give daily doses early so that increased urination does not interfere with sleep. Measure and record regular weight to monitor mobilization of edema fluid. Avoid giving food rich in potassium. Arrange for regular evaluation of serum electrolytes and BUN.

Adverse effects: Fluid or electrolyte imbalance, gynecomastia, GI upset, drowsiness, headache, hyponatremia, tachycardia, hypotension, oliguria, hyperkalemia, confusion, weakness

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Drug Generic Name: Omeprazole Brand name: Losec (CAN) Drug class: Antisecretory drug Proton pump inhibitor

Dose 40 mg PO OD

Mechanism Of Action Gastric acid-pump inhibitor:Suppresses gastric acidsecretion by specificinhibition of the hydrogenpotassium ATPase enzymesystem at the secretorysurface of the gastricparietal cells; blocks thefinal step of acid production

Indications And Contraindications Indications: Short-term treatment of activeduodenal ulcer;First-line therapy intreatment of heartburn orsymptoms of gastroesophageal reflux disease (GERD) Short-term treatment of active benign gastric ulcer; GERD, severe erosiveesophagitis, poorlyresponsive symptomatic GERD Long-term therapy:Treatment of pathologichypersecr etory conditions(ZollingerEllisonsyndrome, multipleadenomas, systemicmastocytosi s);

Side Effects And Adverse Effects Side effects:

Nursing Considerations Give omeprazole before meals, preferably in the morning for once-daily dosing. If needed, also give an antacid, as prescribed. Tell patient to take drug before eating usually before breakfastand to swallow delayed-release capsules or tablets whole. Encourage patient to avoid alcohol, aspirin products, ibuprofen, and foods that may increase gastric secretions during therapy. Advice patient to notify prescriber immediately about abdominal pain or diarrhea.

Eradication of H. pyloriwith amoxicillin ormetronidazole andclarithromycin Contraindications: Contraindicated

Adverse effects: CNS : Headache, dizziness,asthenia, vertigo, insomnia,apathy, anxiety,paresthesias, dreamabnormalities Dermatologic : Rash,inflammation, urticarial ,pruritus, alopecia, dry skin GI : Diarrhea, abdominalpain, nausea, vomiting,constipation, dry mouth,tongue atrophy Respiratory : URI symptoms,cough, epistaxis Other : Cancer inpreclinical studies,back pain, fever

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withhypersensitivity toomeprazole or itcomponents;Use cautiously withpregnancy,lactation

Drug

Dosage

Mechanism of Action

Indication and Contraindications

Side Effects & Adverse Effects Rash, pruritus, urticaria, dyspepsia, nausea, peptic ulcer disease, headache,

Nursing Considerations

Generic Name: betahistinedihyd rochloride

60 mg BID PRN

It has weak agonist activity at histamine H1 receptors and

Indications: Vertigo (dizziness)

Assessment: Assess for allergies, history of asthma and

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moderate antagonist Brand Name: Serc activity at H3 receptors. The antagonist action of Classification: Anti-vertigo betahistinedihydrochl oride at the H3 receptor can be expected to potentiate the release of presynaptic histamine in vivo by blocking the autoinhibitory feedback at histaminergic terminals, its action on medial vestibular nucleus cells is to significantly reduce their responsiveness to histamine. This action of betahistinedihydrochl oride occurs at post-

Contraindications: Patients with hypersensitivity to betahistinedihydrochlorid eor any component of the tablet. Patients with phaeochromocytoma.

dizziness, insomnia

if taking any antihistamine medications.

Implementation: Administer drug as needed.

Raise bed rails, institute safety measures, supervise ambulation

Refer immediately if patient experiences adverse effects.

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synaptic H1 receptors, since it lacks any effect at H2 receptors. The effects of betahistinedihydrochl oride are thus consistent with a partial agonist action at these receptors, with betahistinedihydrochl oride having little excitatory action on its own but reducing the excitatory responses to histamine by occupying H1 receptor sites. Drug Dosage Mechanism of Action Indication and Contraindications Generic Name: isosorbidemono 20 mg PO OD Relaxes vascular smooth muscle with a Indication:Prophylactic management of angina Side Effects & Adverse Effects CNS: Headache, apprehension, Assessment: Monitor blood Nursing Considerations

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nitrate

resultant decrease in venous return and

pectoris Contraindications: Contraindicated with allergy to nitrates, severe anemia, head trauma, cerebral hemorrhage, hypertrophiccardiomyopat hy, narrow-angle glaucoma, postdural hypotension

restlessness, weakness, vertigo, dizziness, faintness

pressure and pulse routinelyduring period of dosage adjustment.

Brand Name: Monoket

decrease in arterial BP, which reduces left ventricular workload

CV: Tachycardia, retrosternal discomfort, palpitations, hypotension, syncope, collapse, orthostatic hypotension, angina, rebound hypertension, atrial fibrillation, postdural hypertension Implementation: Instruct patient to take medication as directed,even if feeling better. Take missed doses assoon as remembered;dailydo ses of GI: Nausea, vomiting, incontinence of urine and feces, abdominal pain, diarrhea isosorbidemononitrat e should be taken 7 hours apart. Do not double doses. Do not discontinue abruptly. GU: Dysuria, impotence, urinary frequency Other: Muscle twitching, pallor, perspiration, cold Caution patient to make position changesslowly to

Classification: Vasodilator

and decreases myocardial oxygen consumption.

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sweat, arthralgia, bronchitis

minimize orthostatic hypotension.

The drug may cause dizziness. Ensure bed side rails.

Inform patient that headache is a common sideeffect that should decrease with continuing therapy.

Drug

Dosage

Mechanism of Action

Indication and Contraindications

Side Effects & Adverse Effects CNS: seizures (high doses),

Nursing Considerations

Generic Name: cefotaxime

2 g IV q8

Bind to the bacterial cell wall membrane,

Indications:

Assessment: Assess for infection

Treatment of the following headache.

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causing cell death. Brand Name: Claforan Therapeutic Effects: Bactericidal action Classification: Antibiotic Cephalosporin Third Generation against susceptible bacteria.

infections caused by susceptible organisms: Intra-abdominal infections and septicemia. Derm: rashes, urticarial Contraindications: Hypersensitivity to cephalosporins; Serious hypersensitivity to penicillins;Renal impairment (decrease dosing/ increase dosing interval recommended for:cefotaxime if CCr<20 mL/min. GU: hematuria, vaginal moniliasis. Hemat:agranulocytosis, eosinophilia, hemolytic anemia, lymphocytosis, neutropenia, thrombocytopenia, thrombocytosis. GI:diarrhea, nausea, vomiting, cramps.

(vital signs; appearance ofwound, sputum, urine, and stool; WBC) at beginningof and throughout therapy.

Before initiating therapy, obtain a history to determineprevious use of and reactions to penicillinsor cephalosporins. Persons with a

Local: pain at IM site, phlebitis at IV site.

negativehistory of penicillin sensitivity may still havean

Misc: allergic reactions including superinfection.

allergic response. Obtain specimens for culture and sensitivity

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beforeinitiating therapy. First dose may be givenbefore receiving results.

Implementation: Monitor injection site frequently for phlebitis (pain, redness, swelling). Change sites every 4872 hr to prevent phlebitis.

If aminoglycosides are administered concurrently, administer in separate sites, if possible, at least 1 hr apart. If second site is unavailable, flush lines between

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medications.

Instruct patient to notify health care professionalif fever and diarrhea develop, especiallyif stool contains blood, pus, or mucus. Advisepatient not to treat diarrhea without consultinghealth care professional.

Drug

Dosage

Mechanism of Action

Indication and Contraindications

Side Effects & Adverse Effects Diarrhea, pruritus, allergic reactions, Increased cholestasis, nausea and

Nursing Considerations

Generic Name: ursodeoxycholic acid

250 mg PO TID

Ursodeoxycholic acid alters the composition of bile, increasing

Indications: Treatment of chronic liver disease in which the flow

Assessment: Assessment of liver functions and

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concentrations of Brand Name: Ursofalk itself and decreasing amounts of toxic bile acids. It also increases Classification: Bile acid bile flow. There is some evidence that ursodeoxycholic acid may also act via an immunological mechanism, details of which are not fully understood.

of bile has stopped for some reason (eg. primary biliary cirrhosis)

vomiting, sleep disturbance

hypersensitivity.

Assess if taking antacid preparations

Contraindications: Contraindicated in patients with chronic liver disease, and hypersensitivity.

such as aluminum salts (Drug interaction).

Implementation: For primary biliary cirrhosis, it is likely that you will be asked to take 2-4 doses daily.

Take ursodeoxycholicacid at the same times each day. Take each of your doses with a snack or just after eating a meal.

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Try to avoid foods that are high in calories or cholesterol. Adhere to the dietitians nutrition plan.

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NURSING THEORY Nursing Theory: Care, Core and Cure Introduction: Concepts: Individual is a 16 year old or older person who had past the acute stage of a long-term illness and was emphasized as unique, capable of growth and learning, and requiring a total person approach Health a state of self-awareness with conscious selection of behaviors that are optimal for that individual Society/ environment is dealt with in relation to the individual Nursing is the participation in care, core, and cure aspects of patient care Theory: Lydia Halls Theory is composed of 3 sub-concepts which are: The care circle, the core circle, and the cure circle. The care, core, cure theory of Lydia Hall is not independent; however it is focused on the relationships between the client and the Healthcare provider. The primary focus is to perform a high quality nursing care given by the nurses and offers a supportive method to people in their post-acute phase of their illness. The Care circle is where the nurturing process takes place. When providing this king of care for a client the nurses goal is the comfort of the client. It involves the concepts of care and comfort of the person and provide for teaching-learning activities. A nurse provides physiological care by helping or assisting the client to complete basic daily biological functions or activities of daily living such as eating, bathing, elimination and dressing. However, by having a clearly defined nurses role allows the nurse to maintain a professional status while incorporating closeness and nurturance in giving care. In addition, it makes the client view the nurse as a potential comforter. The Core circle is about the social relationship that involves therapeutic use of self, and is shared with other members of the health team. By developing a social relationship or interaction with the Theorist: Lydia E. Hall (1906-1969) Received her basic nursing education at York Hospital school of Nursing in York Pennsylvania and graduated in 1927 1937- B.S. in Public Health Nursing, Teachers College, Columbia University, New York 1942- M.A. in teaching Natural Sciences, Teachers College, Columbia University, New York Became the First director of the Loeb Center for Nursing and Rehabilitation

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client, it allows the nurse to have an access of the clients feelings. In doing so, client could give out and allow expressing verbally their feelings regarding their disease and its effect, ad discuss the clients role in recovery. This action could help the client to gain self-identity and further develop maturity. The Cure circle is about the pathological and therapeutic methods and with the other members of the health team taking part in it. The nurse helps the client and family through the medical, surgical and rehabilitative prescriptions made by the physician. And the nurse is an active advocate of the patient. The nurse action in the cure aspect is different with the care aspect because rather than the quality of comforting the nurse takes an action which could inflict pain however, can give advantage to the clients side such as injecting medications to the client or inserting IV. Application: For the application of the case, three days prior to admission of the client, she had diarrhea and was later on diagnosed with liver cirrhosis however it is a denied case, meaning she doesnt know what is her disease and condition. As healthcare providers, for the care aspect, the group focused on the comfort and in providing for teaching-learning activities and assisted in her activities of daily living such as eating, when getting up and walking. For the core aspect, the group encouraged her to verbalize or express her feelings regarding her condition and helped her have a positive outlook in life. For cure aspect, the group administered medications prescribed by the physician and performed tasks that could help improve her condition though it could inflict pain and explained procedures to the client. Assessment: Client EBR, 86 years old, female was admitted to St. Lukes Medical Center last June 20, 2013 due to diarrhea. She was diagnosed of having Liver Cirrhosis. Analysis of Data: Client EBR is the first child in the family. Shes married, a retired teacher and is now a housewife. She has 10 children. The client has a family history of cancer and is a previous smoker for one year. She has a sedentary lifestyle. According to her, she was experiencing abdominal pain and diarrhea and was diagnosed with Hepatitis A and B but it was cured.Client EBR is currently living in a four floor house with good environment. Shes married and has one daughter who has now had own family. She lives with her husband and her daughters own family. Client doesnt have work for how many years and has been involved in playing mahjong. She worked as a teacher but her husband insisted to quit to her job. She loves playing mahjong and at the same time to go shopping. She has no known allergies Diagnosis, outcomes, evaluation The patient was diagnosed of acute pain related to abdominal distended veins as manifested by facial grimace and a pains scale of 7/10. Interventions done were as follows: monitored vital signs, assessed for the character and onset of pain, instructed patient to perform deep breathing exercises, encouraged patient to divert her attention in watching TV, positioned patient in her desired posture,

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encouraged adequate rest. The dependent intervention that was done was to administer Paracetamol + Tramadol as needed as ordered by the doctor. For the collaborative, these interventions were done: assisted nurse on duty in administering PAracetamol + Tramadol for pain, instructed relative to encourage deep breathing exercise when pain re-occurs and advised relative to report further occurrence of pain and other conditions that may aggravate. After 1 hour of effective nursing intervention, the patient manifested no signs of pain. Patient verbalized, Medjonatanggalangsakit.And after 8 hours of effective nursing intervention, patients pain scale decreased from 7/10 to 2/10.

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Nursing Priority No. 1 - Acute Pain Assessment Subjective: Sumasakitangtiyanko kaya gusto konangmagpahinga. Objective: C- kumikirot O- 12:00 PM L- both thigh part D- 1 hour S- Pain scale: 7/10, moderate pain P- intermittent A- environment (+) guarding behavior (+) facial grimace (+)body weakness

Diagnosis

Planning Short Term goal: After 1 hour of effective nursing intervention, the patient will be free from signs and symptoms related to pain.

Intervention Independent: Monitored vital signs.

Rationale

Evaluation Short Term goal:

Acute pain related to abdominal distended veins as manifested by facial grimace and a pain scale of 7/10

To obtain a baseline data To obtain a baseline data and to identify the possible nature of pain To help lessen the pain

Assessed for the character and onset of pain.

After 1 hour of effective nursing intervention, the patient manifested no signs of pain. Patient verbalized, Medjonatanggalangsakit.

Instructed patient to perform deep breathing exercises. Long Term goal: After 8 hours of effective nursing intervention, patients pain scale will decrease. Encouraged patient to divert her attention in watching TV. Positioned patient in her desired posture. Encouraged adequate periods. Dependent: Nurse on duty administered Paracetamol +

Long Term goal: To distract attention and reduce tension After 8 hours of effective nursing intervention, patients pain scale decreased from 7/10 to 2/10.

To promote comfort

To prevent fatigue and further

To decrease pain

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Tramadol PRN as ordered by the doctor Collaborative: Assisted Nurse on Duty in administering Paracetamol + Tramadol PRN as ordered by the doctor. Instructed relative to encourage deep breathing exercise when pain re-occurs. Advised relative to report further occurrence of pain and other conditions that may aggravate.

To help lessen the pain of the patient

To help alleviate the pain

To help in promoting comfort and preventing the

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Nursing Priority No. __ Disturbed Sleep Pattern Assessment Diagnosis Subjective: Patient verbalized, 8 hours angtulogkokasopaputolputollalonakapagsumasakitangtiyanko. Gusto konangmagpahinga. Objective: Seen awake and uncomfortable (+) restlessness (+) body weakness Lovetts Scale: 2 Pain on both thigh part Pain Scale: 7, moderate pain Disturbed sleep pattern related to physical condition as manifested by restlessness

Planning Short Term Goal: After 1 hour of effective nursing intervention, patient will be able to sleep comfortably with no complaints of pain

Intervention Independent: Adjusted ambient lighting.

Rationale

Evaluation Short Term Goal: After 1 hour of effective nursing intervention, patient was able to sleep comfortably with no complaints of pain.

To maintain daytime light

Provided bed time care such as straightening bed sheets. Ensured a quiet environment as preferred by the patient. Performed monitoring and care activities without waking client whenever possible. Collaborative: Requested visitors to leave, close room door quietly. Advised visitors to minimize talking if necessary.

To promote physical comfort

Long Term Goal: After 8 hours of effective nursing intervention, patient will report improved sleeping pattern and will have an adequate sleep

To enhance relaxation

To allow longer periods of uninterrupted sleep

Long Term Goal: After 8 hours of effective nursing intervention, patient reported improved sleeping pattern and adequate sleep

To provide privacy and comfort

To promote comfort

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Discharge Planning Advise to have regular intake of vitamins and minerals to strengthen the bodys immune system. Have a written reminder of the correct medication, time to take, and the right frequency of the medicine on the way home to establish assurance of medication compliance. Advise patient and together with the family to promote a clean environment for safety and health of the patient. Emphasize to the family members the importance of a stress free environment for the recovery of the patient. Discuss significance of personal hygiene and proper hand washing. Increase intake of fruits rich in vitamins to regain immune system. Instruct to drink plenty of water or fluids that are available at home and eat nutritious diet. Instruct the family members to give the client protein rich foods such as meat, fish, eggs and nuts, vitamin K rich foods such as green leafy vegetables, vitamin C rich foods(guava and tomatoes and other citrus fruits), carbohydrates rich food (breads and rice) Advice relatives to help patient to regain cheerfulness by talking to the patient. Instruct the family members to have a check-up or to consult physician once a while to monitor patients condition and for detection of recurrences and other complications that may arise on to it.
Encourage to regularly attend the mass especially during Sundays and other special occasions being celebrated by the church. Advice the patient and relatives to pray for the full recovery of the patient to help the

patient to be strong spiritually.

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Bibliography Books Doenges, M.E., et. al. (2008). Nurses Pocket Guide: Diagnoses, Prioritized Interventions and Rationales, 11th Edition. F.A Davis Company George J.B., (2002). Nursing Theories: The Base for Professional Nursing Practice, 5th Edition. Pearson Education Inc. Gould, B., (2007). Pathophysiology for the Health Professions, 3rd Edition. Elsevier (Singapore) Pte Ltd., 318 - 324 Karch, A.M. (2011). Lippincotts Nursing Drug Guide. Lippincott Williams & Wilkins. Seeley, R.R., et. al (2007). Essentials of Anatomy and Physiology, 6th Edition. Boston: McGrawHill Higher Education. Online Sources http://www.ehow.com/about_5501851_liver-problems-give-diarrhea.html http://www.livestrong.com/article/455329-elevated-liver-enzymes-diarrhea/ http://www.liverfoundation.org/abouttheliver/info/progression/ http://www.uptodate.com/contents/management-of-pain-in-patients-with-cirrhosis http://nursingcrib.com/nursing-notes-reviewer/head-to-toe-assessment-s-extremities/ http://www.livestrong.com/article/341989-ideal-geriatric-weight/ http://www.ece.ncsu.edu/imaging/MedImg/SIMS/Module2/GE2_3.html http://liver.ca/liver-disease/types/cirrhosis/

http://www.mdhil.com/liver-cirrhosis-introduction-causes-and-symptoms/

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http://www.medicalnewstoday.com/articles/172295.php

http://healthengine.com.au/info/INR_Test

http://www.hepb.org/patients/your_blood_tests.htm

http://www.yakimamedicalclinic.com/ExplanationofLaboratoryResults.pdf

http://webarchive.nationalarchives.gov.uk/+/www.dh.gov.uk/en/Publicationsandstatistics/Publications/ AnnualReports/Browsable/DH_4903444

http://www.healthline.com/galecontent/cirrhosis#1

http://www.scribd.com/doc/27336213/Liver-Cirrhosis

http://liver.ca/liver-disease/types/cirrhosis/

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