Liver Cirrhosis Case Presentation

ACKNOWLEDGEMENT
The group would like to express their heartfelt gratitude, sincere appreciation and
profound regards to the following people who, in one way or another, gave guidance,
strength, and encouragement in making this case presentation possible.
First of all, to Almighty God the Father, who granted us the knowledge and skills,
Who send forth the gift of Holy spirit that aided them in completing this study. Without
Him, none of these things would be possible.
To their family, friends, and classmates, for their consideration and unending
support, emotionally, spiritually and financially.
To their clinical instructor, Mrs. Jocelyn Ferraren, RN, for guiding us in the
course of making this case presentation and giving them tips on how to have a good
presentation.
To all medical personnel and staff members of DMC, MED-CP ward, for the
warm accommodation during their clinical exposure and for giving them inspiration to
keep the spirit of caring burning.
To the members of the group, for sharing ideas, cooperating and giving full effort
in making the case presentation successful.
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Lastly, to our client and his family for their acceptance and willingness
to share time, effort and giving us the essential information needed for this
case presentation.
INTRODUCTION
The liver is one of the largest and most complex organs in the body. It stores vital
energy and nutrients, manufactures proteins and enzymes necessary for good health,
protects the body from disease, and breaks down (or metabolizes) and helps remove
harmful toxins, like alcohol, from the body. It is one of the most important organs in the
body since it has many significant functions. A lack or failure to provide proper care of it
may lead to an abnormality or disorder. One of the severe forms that may happen is Liver
Cirrhosis.
Liver Cirrhosis is derived from Greek word kirrhos, meaning "tawny" (the
orange-yellow colour of the diseased liver).It is a chronic disease that causes cell
destruction and fibrosis (scarring) of hepatic tissue. Fibrosis alters normal liver structure
and vasculature, impairing blood and lymph flow and resulting in hepatic insufficiency
and hypertension in the portal vein. Cirrhosis is most commonly caused by alcoholism,
hepatitis B and C and fatty liver disease but has many other possible causes. Some cases
are idiopathic, i.e., of unknown cause. It may be classified by the structural changes that
take place or by the cause of the disorder.
Internationally, liver cirrhosis is the 8thth most common cause of death. It is most
common among people ages 45 – 75, killing more than 25,000 people each year, 50% of
which are alcohol related. In the Philippines and other underdeveloped countries,
2
however, the incidence of liver cancer is rather high. Liver cancer is relatively common
in our country primarily because many Filipinos suffer from cirrhosis of the liver, a major
risk factor for liver cancer. Cirrhosis of the liver precedes 80 percent of all liver cancers;
thus, any condition that predisposes to cirrhosis indirectly causes liver cancer. The usual
cause of liver cirrhosis among Filipinos is chronic hepatitis B, a major public health
problem in the country. Chronic hepatitis B afflicts between 10 and 12 percent of all
Filipinos (i.e., more than 8 million Filipinos). Other less significant causes of cirrhosis
are hepatitis C infection and alcoholism. The latest DOH advisory shows that liver cancer
is the third most common form of cancer among Filipinos—in men, it is the second most
common, while in women, it is the ninth most common. Locally, liver cirrhosis is the 17th
leading cause of death here in Davao.
In connection with it, last February 11, 2010, the Group 3 of section 3H was
assigned on duty at the Davao Medical Center- Communicable Pavilion where they met
their patient Mr. Cute who was diagnosed of having Liver Cirrhosis. They were
motivated to learn more and study the disorder since it was their first time to encounter
such case. Also, the group was more encouraged to choose the patient for their case
presentation in order to acquire better understanding and to gain more knowledge and use
it for the future.
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OBJECTIVES
To have a course of direction, organization and to recognize the essence of this
study, we have set the following objectives:
GENERAL OBJECTIVES
After rendering effective nursing care for three days at the Davao Medical Center,
MED-CP Ward, we aim:
• To provide an extensive study about Community acquired pneumonia ascites
secondary to liver cirrhosis for us to gain better understanding about the disease
and be equipped with competence in dealing with related situations in the
future;
• To improve our skills in doing relevant interventions which promote wellness to
persons having the disease;
• Not only to understand the situation of the client and their families who are
confronted with the disease but also to empathize with them.
SPECIFIC OBJECTIVES
 Find a case in the DMC, MED-CP ward within the three-day duty;
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 Establish a good interpersonal relationship with our chosen client as well as to his
significant others;
 Acquire necessary data of our client which are relevant to our case study;
 Trace the patient’s family lineage and present remarkable familial disease;
 Trace the health history of the client and the family by collecting information both
from the past and present illnesses;
 Evaluate the client’s development guided by Erik Erikson, Robert Havighurst and
Jean Piaget’s Theory;
 Define the complete diagnosis of our client guided by three different sources;
 Perform cephalocaudal assessment to the client thoroughly;
 Discuss the systems involved in the development of the disease in the human
anatomy and physiology;
 Present the etiology and symptomatology of the disease process with each of its
Sends thesignal
rationales and identify which are present on the client’s case; to the medulla
oblongata to
 Trace the pathophysiology of the disease as experienced by our client and presentcough
Crackles and
it through a schematic diagram; Wheezes
The mucosal
 Present and analyze the doctor’s order in chronological manner; lining nerves
detects the
excessive
 Explain and interpret both actual and possible diagnostic studies including the
secretions
indication, result, and their implications; Exudates

production and
Edema
Cilia try to
propels the
mucous out of
5 system
the
Stimulates
mucous
large quantities
Chemical
mediators irritate
the goblet cells
of the bronchial
 Discuss the different drugs taken by the patient with corresponding nursing lining
intervention; Stimulates
Diapedesis and
positive
 Identify different nursing theories made by Florence Nightingale, Virginia
chemotaxis of
Leukocytes
Henderson and Lydia Hall and relate it on the patient’s conditions;
Inflammation of
the Parenchyma
 Formulate specific, measurable, attainable, realistic, and time-bounded nursing
Fever
care plans with corresponding rationales for each of the nursing interventions;
Obstruction of
the airway
 Evaluate the client’s progress with our continuous care;
Cilia fail to sweep
the mucous
 Render health teachings or appropriate nursing interventions necessary to the
because of
thickness
client and family as well;
Histamine causes
vasodilation
 Present a discharge plan for the patient
Prostaglandin
and Leukotrienes
 Present and justify the prognosis of our patient causes blood
vessels to be
more permeable
 Provide recommendations for the better management of patient with the same
Damage of the
disease in the future endeavor; cells release
Histamine,
 Accomplish our case presentation. Prostaglandins
and Leukotrienes
Blood vessels
leak. Damage on
the blood vessels
is scant
Predisposing factors:
Age- elderly adults

(age above 70)
Precipitating factors:
Smoking
Alcoholism
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Hematemesis
and
GI bleeding
If treated:
MGT:
Transplantatio
n
Paracentesis
Medications
plasmaphorese
s
PATIENT’S DATA
If not treated
Progressive
Name: Mr. Cutie liver
destruction,
Age: 72 years old systemic
counsel
Sex: Male
Hepatic
Date of birth: May 23, 1937 encephalopath
y
Place of birth: Igacos, Davao City
Toxic
Current address: Manablay Callawa, Buhangin Davao City substance
production
Occupation: Farmer
Mental
Nationality: Filipino retardation
Hepatic coma
Religion: Christianity (Roman Catholic)
DEATH
Civil Status: Married
- Destruction
of cell
membranes
CLINICAL DATA causes red
blood cells to
Date of admission: February 6, 2010 burst
Time of admission: 04:09PM Nursing Resp:
-Give
Mode of admission: Ambulatory
supplements
containing
Chief complaint: malaise, loss of appetite, nausea, and black tarry stool
Vit.E
Nursing Resp:
7
-Give Vit.D
fortified milk
-Give
supplementati
on
Ward: MED - CP
Varices and
Admitting physician: Dr. Emerson R. Taghoy hemorrhoids
Vital signs upon admission: May rupture

and bleed
Temp: 36.6 C
Vitamin D
BP: 90/60 mmHG
Decrease
PR: 65 bpm absorption of
calcium and
RR: 28 cpm Phosphorus
from the GI
Final diagnosis: CAP MR Ascites 2’ Liver Cirrhosis tract
Source: Significant others and patient's chart Vitamin E
Decrease
against
oxidative
damage
caused by free
radicals
Nursing Resp:
- Monitor urine
output
- Elevate
edematous
extremities
-Reposition
every 2 hours if
patient
- Administer
diuretics as
prescribed
- Tell patient to
use antiembolic
stockings or
bandage
8
Nursing Resp:
-Give
-prevent injury
-decrease risk
for infection
Development of
GENOGRAM tissues, and
resistance to
infections Grandmade
Lolo-har Lola-har
r
Body malaise
Decreased
source of
MAMA-HARenergy
Tita- PAPA-HAR
Manong Tito   Auntie  Kol 
har 
Decreased
glucose in the
body
Decreased
vitamin K
Gwaping Gwafa  Pefa  A
Boylet  Keks  Vitamin Cutie●

Vitamin
deficiency
Nursing Resp:
-Encourage
intake of Vit.K
LEGEND:
rich foods
MALE Nursing Resp:
FEMALE Nursing Resp:

-Assess pain
scale
 DECEASED
-Monitor VS
 TB
-Administer
 HYPERTENSION analgesic as 9
● LIVER CIRRHOSIS ordered
Absence of
bilirubin in the
feces
Bile unable to
FAMILY BACKGROUND AND HEALTH HISTORY reach Gi tract
Clay colored
Family History stool
ASCITES
Most of the significant details gathered on the interview we had came from
Third spacing
occurs
Mr.Cutie’s wife and daughter since he was not able to verbalize due to his condition.
JAUNDICE
Upon the interview, we found out that no one in the family had any of the sickness that
Speeds up
the patient had namely Liver Cirrhosis and Community Acquired Pneumonia. destruction of
RBCs
Cutie is a married man with three children. He is the main decision maker in the
Chronic
passive
family as evidenced by his wife verbalizing,” siya man gyud ng gabuot ug unsay maayo
congestion
para sa amoa”. In regards to their health, several members of their family specifically the
Spleen
patient, his wife and his daughter have hypertension which was all diagnosed by
GI the
tract
physician, whom they usually consult in Polyclinic Health Center where their neighbor
Stomach pain
works as a nurse. However they were not able to recall the name of the physicianAltered
they bowel
function
consulted, but they were able to remember the month and year that their condition was
Blood
regurgitation
diagnosed: on August of the year 2009. In reference to the diagnosis that was given by
to the spleen ,
the physician, maintenance medication was given to the three of them howeverGIthey tract
Prominent
forgot since they only used the said the medication for about two weeks. Finances were a
distended
factor since they were not able to comply the medication prescribed by the physician.blood vessels
in the stomach
Bleeding
The family does not seek medical advice until the condition they have worsens as
tendencies
stated by Cutie’s wife. All of them had experienced fever, flu, cough, colds, stomach
Shunting of
pains, etc. but again they don’t seek medical attention until condition becomes worse.blood from
portal vessels
to vessels with
lower pressure
Decrease in
osmotic
pressure
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KIDNEYS
Signal for
aldosterone
release
Na+
Lifestyle absorption/
H2O retention
As verbalized by the patient’s wife, the patient at his young age was a typicalK+
excretion
adolescent who goes with friends and often explores things around. As stated, the patient
EDEMA
was curious at all things and because of that he was inclined to a number of vices which
No free blood
passage
may actually have affected his health status. He was smoking badly as he was able to
Backflow of
consume 1-2 packs of cigarette a day and drinks enormously as he was able to drink 1
bile
long neck of Tanduay on his own. At times, he goes beyond 1 long neck and even drinks
Bile goes to
the blood
half a gallon of “Tuba” when he is not yet drunk. As stated by his wife, his husband doesstream
not stop drinking unless he becomes drunk. As the normal things go as stated by his
Formation of
collateral
wife, the patient and his drinking colleagues use same glass whenever they drink. All of vessels
blood
in the GI
these had been the lifestyle of the client since then. system
Accumulation
When he reached his adulthood, he worked as a farmer and still continued to
of ammonia
drink and smoke whenever he has time. He often sleeps at 10:00pm and wakes Unable
up at to
convert
5:00am then takes his breakfast and goes to his work. He takes his break from 11:30am
ammonia to
urea
up to 12:30pm and thus eats his lunch. He goes to work and ends at 5:00pm. What he
Decreased
normally does is clean the plantation and get rid of unwanted growth of grasses allglucogenesis
over
the place that may alter the good growth of the trees that were present. Whenever he has
Decrease in
albumin
spare time such as weekends which is his rest day from work, he stays at home, watches
production
TV or talks with his children or goes to his neighbor and drinks. He had such routine Obstruction
until of
portal
last year, 2009, when he finally had stopped doing his usual things when he was
circulation
diagnosed of having hypertension. He drinks rarely and smokes only about 2-4 sticks aPortal
hypertension
day compared before when he was not yet diagnosed with hypertension.
Liver
Decreased
RBC
11
Body malaise,
pallor
Change to Fowler’s
position, assess CRT
Decreased
erythropoietin
Diet Hepatic
fibrosis
The patient’s wife was able to notice that his husband was fond of eating fatty
Impaired
hepatocyte
foods such as “taba sa baboy.” Whenever they have this kind of viand, she reported that
function
her husband would really eat a lot of these when available. She also mentioned that her changes
Matrix
husband liked eating salty foods such as dried fish and ginamos almost every day. It Extracellular
has
matrix
been said by the patient’s wife that these viands are the usual part of every meal.components
In
Predisposing
addition to that, they often take canned goods. As the patient’s wife verbalized “Syempre
Factors:
dong ana man gyud na sa pobre”. Moreover, drinking coffee every morning has always
Male
been the routine of his husband, still reported by his wife.
Age (45-75 yrs
old)
Race
History of past illness

Race: Asian
Other than ordinary fever, cough, and flu, which they treat only through over-the-
Pathophysiology
counter drugs and no consultations, the patient didn’t have any serious illness. This was
of Liver
Cirrhosis
the case, however, until he reached the old age when different signs and symptoms
started to manifest, increased blood pressure arise. He then sought medical advice since
Precipitating
there were other manifestations of hypertension such as dizziness, nausea and pain on his
factors:
nape. Then he found out that he has hypertension as diagnosed. Only through daily BP
Chronic
alcoholism
taking at Santo Tomas Clinic, a clinic just around the area, did they found out about this
Diet
gradual increase in blood pressure. It was treated and taken cared of through unrecalled
Smoking
medications that were prescribed to him by the said clinic.
sMOK
Portal
obstruction
Grandfader
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History Of Present Illness
For the past years, the patient did not have any serious illness related to his
present condition. But on January 23, 2010, 2 weeks prior to the patient’s admission, he
had headache, chest pain, dull abdominal pain, felt nauseated and dizzy. The patient and
even his wife had never thought that it was a manifestation of an underlying problem and
so they did not take it seriously. They did not seek medical attention; instead his wife
gave him over-the-counter medication such as Paracetamol for his headache which he
took four times during that day and one Diatabs for his stomach pain which is actually
not appropriate since the medication itself was wrong and that the underlying condition
was not taken into consideration. The condition however did not last long since it was
relieved one day after it occurred. The patient and his wife were relieved and thought that
it was just a “Panuhot and Kabuhi”.
One week prior to patient’s admission to the hospital, his wife noticed that his
husband had abdominal distention which she abruptly noticed as evidenced by her
verbalization, “Dili man kaayo na siya dako ug tiyan sa una. Murag ning kalit ra man.
Atong mga last week sa January ra pud nako nabantayan”.
On the 2nd day of February, 2010, four days prior to admission to the hospital the
patient sought consultation at the Emergency Room since the patient felt loss of appetite,
stomach pain which radiated to the patient’s back and prandial vomiting. Despite the
manifestations seen on the client, he was discharged and was requested to have an
ultrasound of the abdomen. Aside from that, it was again diagnosed that he has
hypertension so antihypertensive medications were prescribed. Days had gone and on the
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6th of February 2010, the patient experienced body malaise, loss of appetite, nausea, and
black tarry stool which were his chief complaint that resulted to his admission to Davao
Medical Center.
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DEVELOPMENTAL DATA
Erik Erikson’s Psychosocial Theory of Development

Theory Stage Result and Justification
Erik Erikson, in his Integrity versus Despair The patient has fully
Psychosocial Theory of (65 years old and above) achieved integrity.
development, believed that This stage focuses on According to his wife,
personality develops in a reflecting back on life. Cutie is already contented
series of stages. Erikson's Integrity means feeling at with his life. His wife
theory proposes that life is a peace with oneself and the verbalized "Kamao ka
sequence of developmental world. No regrets or dong, miskan ana ra na
stages or levels of recriminations. Despair akong bana, wala gyud na
achievement. He described and/or 'Disgust' represent the siya nagmahay ug taman-
eight stages of development opposite disposition: feelings taman sa mga
and in each stage signals a of wasted opportunities, nangahitabo sa among
task that must be regrets, wishing to be able to kinabuhi. Simple ra nga
accomplished. Our progress turn back the clock and have panginabuhi ra ang
through each stage is in part a second chance. Those who among panginabuhi pero
determined by our success, are unsuccessful during this wala gyud na siya nag
or lack of success, in all the phase will feel that their life dahum na mudato.
previous stages. Erikson has been wasted and will Kontento na siya sa amo.
also believed that the more experience many regrets. The Okay na sa iya kay
success an individual has at individual will be left with napadako niya ug maayo
each developmental stage, feelings of bitterness and among mga anak,
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the healthier the personality despair. Those who feel makahikahos mi sa pang
of an individual is. proud of their adlaw-adlaw." Despite of
accomplishments will feel a it, the patient was not able
sense of integrity. to send his three children
Successfully completing this in college. Moreover, the
phase means looking back patient has been alcoholic
with few regrets and a for almost 60 years and
general feeling of been smoking since his
satisfaction. These teenage years. These
individuals will attain habits are wasted
wisdom, even when opportunity and Mr. cutie
confronting death. has not attained the
wisdom since he was not
able to decipher that his
vices would affect his
health in the long run.
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Robert Havighurst’s Developmental Task Theory
Havighurst believes that in Later Maturity (60 and The patient has not fully
every developmental stage, above) achieved this stage since
certain tasks are needed to some tasks are not

This stage in a person’s life
be accomplished for one’s accomplished. He has his
is concerned with the
progression. In his theory, circle of friends whose
achievement of the following
he proposes that growth and age is almost same with
tasks:
development is occurring his. They drink and play
1. Adjusting to
during six stages in life, cards together. But
decreasing physical
each associated with six to according to his wife, he
strength and health.
ten tasks to be learned. is not still used to his
Havighurst identified Six 2. Adjusting to deteriorating strength. We
Major Stages in human life retirement and always wanted to work or
covering birth to old age. reduced income. at least to keep his self
Infancy & early childhood busy, same as the thing he

3. Adjusting to death of
(Birth till 6 years old), has been doing when he
a spouse.
Middle childhood (6-13 was still younger, but his
years old), Adolescence (13- 4. Establishing an strength is limiting him
18 years old), Early explicit affiliation already. Therefore, he was
Adulthood (19-30 years with one’s age group. not able to adjust from his
old), Middle Age (30- 5. Meeting civic and physical limitation due to
60years old), and Later social aging.
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maturity (60 years old and responsibilities.
over). From there,

6. Establishing
Havighurst recognized that
satisfactory physical
each human has three
living arrangements.
sources for developmental
tasks. They are:
* Tasks that arise from
physical maturation:
Learning to walk, talk,
control of bowel and urine,
behaving in an acceptable
manner to opposite sex,
adjusting to menopause.
* Tasks that arise from
personal values: Choosing
an occupation, figuring out
ones philosophical outlook.
* Tasks that have their
source in the pressures of
society: Learning to read,
learning to be responsible
citizen. A developmental
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task is “a task which arises
at or about a certain period
in the life of an individual,
successful achievement of
which leads to his happiness
and to success with later
tasks, while failure leads to
unhappiness in the
individual, disapproval by
society, and difficulty with
later tasks”.
JEAN PIAGET’S THEORY OF COGNITIVE DEVELOPMENT
19
Jean Piaget proposed a Formal Operations The patient did not
sequence of cognitive achieve this cognitive

This stage is characterized by
development that stage. The patient is a
formal reasoning. It is in this
emphasized the relationship chronic alcohol drinker
stage that a person’s
between action and thought. and a smoker. From that
acquisition of the ability to
Each phase in his theory is alone, he must have
think abstractly, reason
characterized by the ways in thought that this will have
logically and draw
which the person interprets a bad effect on his health.
conclusions from the
and uses the environment. He was not able to reason
information available is
The individual learns by out logically and did not
measured.
interacting with the able to see the bigger
environment through picture that can be brought
assimilation, about by his vices that
accommodation and these will result to illness.
adaptation.
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DEFINITION OF COMPLETE DIAGNOSIS
CAP MR Ascites 2’ Liver Cirrhosis
Community-Acquired Pneumonia
Community-acquired pneumonia (CAP) is one of the most common infectious
diseases addressed by clinicians. CAP is an important cause of mortality and morbidity
worldwide.
CAP is usually acquired via inhalation or aspiration of pulmonary pathogenic
organisms into a lung segment or lobe. Less commonly, CAP results from secondary
bacteremia from a distant source, such as Escherichia coli urinary tract infection and/or
bacteremia. CAP due to aspiration of oropharyngeal contents is the only form of CAP
involving multiple pathogens.
Source: Handbook of Medical-Surgical Nursing 3rd Edition by Springhouse, 2006
Community-acquired pneumonia (CAP) is a disease in which individuals who
have not recently been hospitalized develop an infection of the lungs (pneumonia). CAP
is a common illness and can affect people of all ages. CAP often causes problems like
difficulty in breathing, fever, chest pains, and a cough. CAP occurs because the areas of
21
the lung which absorb oxygen (alveoli) from the atmosphere become filled with fluid and
cannot work effectively.
Patients at moderate risk (class IV of the Pneumonia Severity Index) and high risk
(class V) should be hospitalized, given their much higher rates of death and
complications. In general, most such patients are elderly and have two or more
additional poor prognostic factors, such as serious coexisting conditions, abnormal vital
signs, and abnormal laboratory values.
Source: Medical-Surgical Nursing: A Psychophysiologic Approach by Luckmann and
Sorensen, 2003
Patients with community-acquired pneumonia often present with cough, fever,
chills, fatigue, dyspnea, rigors, and pleuritic chest pain. When a patient presents with
suspected community-acquired pneumonia, the physician should first assess the need for
hospitalization using a mortality prediction tool, such as the Pneumonia Severity Index,
combined with clinical judgment.
Pneumonia Severity Index
Patient Characteristics Points
Demographics
Male Age (years)
Female Age (years) –
10
22
Patient Characteristics Points
Nursing home resident + 10
Comorbid illness
Neoplastic disease + 30
Liver disease + 20
Congestive heart failure + 10
Cerebrovascular disease + 10
Renal disease + 10
Physical examination findings
Altered mental status + 20
Respiratory rate >30 breaths per minute + 20
Systolic blood pressure < 90 mm Hg + 20
Temperature < 35°C (95°F) or >40°C (104°F) + 15
Pulse rate >125 beats per minute + 10
Laboratory and radiographic findings
Arterial pH < 7.35 + 30
Blood urea nitrogen >64 mg per dL (22.85 mmol per L) + 20
Sodium < 130 mEq per L (130 mmol per L) + 20
Glucose >250 mg per dL (13.87 mmol per L) + 10
Hematocrit < 30 percent + 10
Partial pressure of arterial oxygen < 60 mm Hg or oxygen percent + 10
saturation < 90 percent
Pleural effusion + 10
Total points: _______
Mortality % (No. of Recommended site of
Point total Risk Risk class patients) care
No Low I 0.1 (3,034) Outpatient

predictors
≤ 70 Low II 0.6 (5,778) Outpatient
71 to 90 Low III 2.8 (6,790) Inpatient (briefly)
91 to 130 Moderate IV 8.2 (13,104) Inpatient
>130 High V 29.2 (9,333) Inpatient
Source: Stephanie Wessel Reyburn, M.D., M.P.H., Mayo School Of Graduate Medical
Education, Rochester, Minnesota - Http://Www.Aafp.Org/Afp/2006/0201/P442.Html
Accessed On February 21, 2010
23
Ascites
Ascites is an accumulation of serous fluid in the abdominal cavity. The fluid
accumulates primarily because of low production of albumin by the failing liver. An
insufficient amount of protein in the capillaries causes plasma to seep into the abdominal
cavity. The accumulated fluid causes a markedly enlarged abdomen. The fluid may cause
severe respiratory distress as a result of elevation of the diaphragm.
Source: Understanding Medical Surgical Nursing by Williams and Hopper, 2007
Ascites
Ascites is the accumulation of fluid (usually serous fluid which is a pale yellow
and clear fluid) in the abdominal (peritoneal) cavity. The abdominal cavity is located
below the chest cavity, separated from it by the diaphragm. Ascitic fluid can have many
sources such as liver disease, cancers, congestive heart failure, or kidney failure.
Sorensen, 2003
Ascites
24
Ascites is diagnosed by inspection of the fluid-filled abdomen, percussion for
dullness and tapping of massive ascites to produce fluid waves. When these signs are
accompanied by other manifestations of disease associated with ascites, usually cirrhosis,
identification of the problem is validated.
Liver Cirrhosis
Liver cirrhosis is the final stage of many types of liver injury. The cirrhotic liver
varies in appearance, but a nodular consistency with hands of fibrosis (scar tissue) is
prominent.
The cirrhosis patient frequently presents with problems such as ascites,
gastrointestinal bleeding and encephalopathy. The disease often progresses quietly until
such as emergency occurs. Hepatomegaly (enlarged liver), splenomegaly (enlarged
spleen), vascular changes, or abnormal laboratory tests may be the first indicator in the
patient who is
25
Sorensen, 2003
Liver Cirrhosis
A chronic hepatic disease, cirrhosis is characterized by diffuse destruction and
fibrotic regeneration of hepatic cells. As necrotic tissue yields to fibrosis, this disease
alters liver structure and normal vasculature, impairs blood and lymph flow, and
ultimately causes hepatic insufficiency.
Liver Cirrhosis
Cirrhosis is a consequence of chronic liver disease characterized by replacement
of liver tissue by fibrous scar tissue as well as regenerative nodules (lumps that occur as a
result of a process in which damaged tissue is regenerated) leading to progressive loss of
liver function.
Source: Blackwell’s Dictionary of Nursing 5th Edition, 2004
26
27
PHYSICAL ASSESSMENT
Date and Time Performed: February 11, 2010 at 5:00 pm
Personal Data
Cutie is a male patient admitted to the Med CP of Davao Medical Center. He is 72
years old and was born on May 23, 1937. He was born in IGACOS, Davao City and is
currently living at Buhangin, Davao City. He is Filipino and a Christian (Roman
Catholic) in religion. He is married. The reason for his admission is malaise, loss of
appetite, nausea, and black stools experienced on the 6th of February, 2010.
Health History
The patient claimed that he never had any past illnesses that lead him to an
admission to a hospital. It was just a number of feverish experiences, cough, colds and flu
which he had. It was stated by his wife upon our interview that he was diagnosed with
hypertension a year ago and had maintenance medications. And just a month ago, he then
had chest pain, dizziness, nausea, and body malaise.
General Survey
Received lying on bed unconscious as evidenced by the patient not responding to
verbal and pain stimuli. Patient had an IVF of D5NaCl at 80cc/hr infusing well at left
metacarpal vein; with endotracheal tube with O2 at 5-7 L/min connected to a bag valve;
with Foley catheter connected to a Urobag draining 100 cc of dark yellow colored urine.
He was untidy as the patient was with dirty feet and untrimmed and dirty nails.
28
Vital Signs:
BP- 110/70mmhg Temperature- 38.3
PR- 96bpm RR- 24
Skin
The patient had jaundice with uniform skin color all throughout the body except
under his axillae, which is darker. His skin folds and axillae were moist. Skin temperature
was uniform in all extremities when touched. Senile skin was noted.
Hair
Upon inspection, hair was short and white in color. His hair was thin and evenly
distributed as evidenced by the absence of areas of alopecia along the scalp. No infection
or infestations were noted upon inspection and palpation of the patient’s hairline and
scalp. Dandruff was noted on patient’s scalp however there were no lesions, lumps, or
masses upon palpation.
Nails
Clubbing of nails was noted on patient. Upon palpation, nail base was firm and
fingernails had a rough texture. Epidermis surrounding the nails was intact and no
lesions were noted. Nails were long, dirty and untrimmed. Toenail surface was slightly
curved and rough.
29
Skull and Face
Skull was rounded and normocephalic. Symmetry in anatomy of face was noted.
Eyes and Vision
Hair of eyebrows was evenly distributed and periorbital skin was intact without
swelling or inflammation. Eyebrows were symmetrically aligned. Upon inspection, skin
of eyelids was intact and no discharges and discolorations were present. Icteric sclera was
noted. Iris were black in color, and had a round, smooth border. Pupillary response to
illumination was sluggish and equal on both eyes as evidenced by constricting of both
illuminated and non-illuminated pupils upon illumination. Patient does not wear glasses:
visual acuity when he was still conscious and awake was grossly normal as stated by his
wife.
Ears and Hearing
Upon inspection, auricles were of the same color with facial skin, were
symmetrically aligned with each other, and were aligned with the outer canthus of each
eye. Cerumen was present but was not impacted or excessive in amount. Upon palpation,
auricles were firm, and not tender as evidenced by the auricle being pulled upward,
downward, and backward without resistance, and the pinna being folded forward without
resistance and recoiling after folding. Patient was unresponsive since he is in comatose.
30
Nose
Upon inspection, external nose was symmetrical. No abnormal discharges or
flaring were noted. Also, the nose was with uniform color with facial skin. Nasal septum
was intact and in midline. Patient was with NGT on his right nares.
Mouth
Upon inspection, endotracheal tube with O2 at 5-7 L/min connected to bag valve
was noted. Outer lips were brownish pink and were dry. Teeth were shiny and yellow in
color.
Neck
Upon inspection, neck veins were not distended or visible. Shoulder muscles were
of anatomically symmetrical.
Thorax and Lungs
The skin over the posterior thorax was intact and uniform in color with
the rest of the body. Also, chest expansion was symmetrical when air is administered
through the endotracheal tube with O2 at 5-7 L/min connected to a bag valve. Crackles
were noted upon auscultation.
Cardiovascular and Peripheral Vascular
Peripheral pulses were regular and present on all four extremities. Slow capillary
refill time of 4-5 seconds gathered upon three checks was noted.
31
Chest
No masses, lesions or any unusuality noted on patient’s chest.
Abdomen
Upon inspection, distended abdomen and ascites was noted. Abdomen was supple
when palpated. Size of abdomen was observed to be not appropriate for patient’s body.
Abdominal girth of 39 inches was taken. Caput medusae noted on the skin of the
abdomen.
Genito-urinary
Upon inspection, no swelling, lesion or mass noted on the genitals of the patient.
Patient is with Foley catheter which is connected to a Urobag draining 100 cc of dark
yellow colored urine.
Back and Extremities
Patient was not able to manifest movements on the upper body and lower body
since the patient was not conscious during the assessment. Bones appear to have no
deformities. Elbows have no deformities. However a grade 1 pitting edema was noted on
all four extremities as skin does not immediately (approximately 4 seconds) go back to its
normal state when pressure is applied.
32
ANATOMY AND PHYSIOLOGY
Liver
The liver is the largest internal organ in the
body, and weighs about 3 pounds in an adult. The
liver is located in the right upper quadrant of the
abdomen, just below the diaphragm. A thick
capsule of connective tissue called Glisson's capsule
covers the entire surface of the liver. The liver is
divided into a large right lobe and a smaller left lobe. The falciform ligament divides the
two lobes of the liver. Each lobe is further divided into lobules that are approximately 2
mm high and 1 mm in circumference.
These hepatic lobules are the functioning units of the liver. Each of the
approximately 1 million lobules consists of a hexagonal row of hepatic cells called
hepatocytes. The hepatocytes secrete bile into the bile channels and also perform a
variety of metabolic functions. Between each row of hepatocytes are small cavities called
sinusoids. Each sinusoid is lined with Kupffer cells, phagocytic cells that remove amino
acids, nutrients, sugar, old red blood cells, bacteria and debris from the blood that flows
through the sinusoids. The main functions of the sinusoids are to destroy old or defective
red blood cells, to remove bacteria and foreign particles from the blood, and to detoxify
toxins and other harmful substances. Approximately 1500 ml of blood enters the liver
each minute, making it one of the most vascular organs in the body. Seventy-five percent
33
of the blood flowing to the liver comes through the portal vein; the remaining 25% is
oxygenated blood that is carried by the hepatic artery.
The hepatic portal system begins in the capillaries of the digestive organs and
ends in the portal vein. Consequently, portal blood contains substances absorbed by the
stomach and intestines. Portal blood is passed through the hepatic lobules where nutrients
and toxins are absorbed, excreted or converted.
Restriction of outflow through the hepatic portal system can lead to portal
hypertension. Portal hypertension is most often associated with cirrhosis. Patients usually
present with splenomegaly, ascites, GI bleeding and/or portal systemic encephalopathy.
The consequences of portal hypertension are due to
portal systemic anastomosis formed by the body as an attempt
to bypass the obstructed liver circulation. These collateral
vessels form along the falciform ligament, diaphragm, spleen,
stomach and peritoneum. The collaterals find their way to the
renal vein where blood drained from the digestive organs is let
into the systemic circulation.
The liver is responsible for important functions, including:
• Bile production and excretion
• Excretion of bilirubin, cholesterol, hormones, and drugs
• Metabolism of fats, proteins, and carbohydrates
• Enzyme activation
34
• Storage of glycogen, vitamins, and minerals
• Synthesis of plasma proteins, such as albumin and globulin, and clotting factors
• Blood detoxification and purification
The liver synthesizes and transports bile pigments and bile salts that are needed for fat
digestion. Bile is a combination of water, bile acids, bile pigments, cholesterol, bilirubin,
phospholipids, potassium, sodium, and chloride. Primary bile acids are produced from
cholesterol. When bile acids are converted or "conjugated" in the liver, they become bile
salts.
Bilirubin is the main bile pigment that is formed from the breakdown of heme in red
blood cells. The broken-down heme travels to the liver, where is it secreted into the bile
by the liver. Bilirubin production and excretion follow a specific pathway. When the
reticuloendothelial system breaks down old red blood cells, bilirubin is one of the waste
products. This "free bilirubin" is a lipid soluble form that must be made water-soluble to
be excreted. The conjugation process in the liver converts the bilirubin from a fat-soluble
to a water-soluble form. The liver also plays a major role in excreting cholesterol,
hormones, and drugs from the body.
The liver plays an important role in metabolizing nutrients such as carbohydrates,
proteins, and fats. The liver helps metabolize carbohydrates in three ways:
• Through the process of glycogenesis, glucose, fructose, and galactose are
converted to glycogen and stored in the liver.
35
• Through the process of glycogenolysis, the liver breaks down stored glycogen to
maintain blood glucose levels when there is a decrease in carbohydrate intake.
• Through the process of gluconeogenesis, the liver synthesizes glucose from
proteins or fats to maintain blood glucose levels.
The liver synthesizes about 50 grams of protein each day, primarily in the form of
albumin. Liver cells also chemically convert amino acids to produce ketoacids and
ammonia, from which urea is formed and excreted in the urine. Digested fat is converted
in the intestine to triglycerides, cholesterol, phospholipids, and lipoproteins. These
substances are converted in the liver into glycerol and fatty acids, through a process
known as ketogenesis.
Prothrombin and fibrinogen, substances needed to help blood coagulate, are both
produced by the liver. The liver also produces the anticoagulant heparin and releases
vasopressor substances after hemorrhage.
Liver cells protect the body from toxic injury by detoxifying potentially harmful
substances. By making toxic substances more water soluble, they can be excreted from
the body in the urine. The liver also has an important role in vitamin storage. High
concentrations of riboflavin or Vitamin B1 are found in the liver. 95% of the body's
vitamin A stores are concentrated in the liver. The liver also contains small amounts of
Vitamin C, most of the body's Vitamin D stores, and Vitamins E and K.
36
Biliary tract
The biliary tract (or biliary tree) is the common anatomy
term for the path by which bile is secreted by the liver on its way
to the duodenum, or small intestine, of most members of the
mammal family. It is referred to as a tree because it begins with
many small branches which end in the common bile duct,
sometimes referred to as the trunk of the biliary tree. The duct is
present along with the branches of the hepatic artery and the
portal vein forming the central axis of the portal triad. Bile flows in opposite direction to
that of the blood present in the other two channels. The liver is usually excluded, but
sometimes included. Pressure inside in the biliary
tree can give rise to gall stone and lead to cirrhosis
of the liver. Blockage can cause jaundice.
The biliary tract can also serve as a reservoir
for intestinal tract infections. Since biliary tract is
an internal organ, it has no somatic nerve
supply,and,therefore,colicky pain due to infection
and inflammation of the biliary tract is not a
somatic pain but it may be caused by luminal distension which causes stretching of the
wall (the same mechanism of pain in intestinal colic in intestinal obstruction in which
intestine also do not have somatic nerve supply)
37
The path is as follows:
• Bile canaliculi >> Canals of Hering >> bile ductules (in portal tracts) >>
intrahepatic bile ducts >> left and right hepatic ducts >>
• merge to form >> common hepatic duct >>
• exits liver and joins >> cystic duct (from gall bladder) >>
• forming >> common bile duct >> joins with >> pancreatic duct >>
• forming >> ampulla of Vater >> enters duodenum
The anatomy of the biliary tree is a little complicated, but it is important to
understand. The liver's cells (hepatocytes) excrete bile into canaliculi, which are
intercellular spaces between the liver cells. These drain into the right and left hepatic
ducts, after which bile travels via the common hepatic and cystic ducts to the gallbladder.
The gallbladder, which has a capacity of 50 milliliters (about 5 tablespoons), concentrates
the bile 10 fold by removing water and stores it until a person eats. At this time, bile is
discharged from the gallbladder via the cystic duct into the common bile duct and then
into the duodenum (the first part of the small intestine), where it begins to dissolve the fat
in ingested food.
The liver excretes approximately 500 to 1000 milliliters (50 to 100 tablespoons)
of bile each day. Most (95%) of the bile that has entered the intestines is resorbed in the
last part of the small intestine (known as the terminal ileum), and returned to the liver for
reuse.
38
The many functions of bile are best understood by knowing the composition of bile:
1. Bile Salts (cholates, chenodeoxycholate, deoxycholate): these are produced by the
liver's breakdown of cholesterol. They function in bile as detergents that dissolve
dietary fat and allow it to be absorbed. Hence, disruption of bile excretion disrupts
the normal absorption of fat, a process called malabsorption. Patients develop
diarrhea because the fat is not absorbed (steatorrhea) , and develop deficiencies of
the fat-soluble vitamins (A, D, E, and K).
2. Cholesterol and phospholipids-while only
4% of bile is cholesterol, the secretion of
cholesterol and its metabolites (bile salts)
into bile is the body's major route of
elimination of cholesterol. Phospholipids,
which are components of cell membranes,
enhance the cholesterol solubilizing
properties of bile salts. Inefficient excretion
of cholesterol can cause an increased serum
cholesterol. This predisposes to vascular disease (heart attacks, strokes, etc.)
3. Bilirubin-while this comprises only 0.3% of bile, it is responsible for bile's yellow
color. Bilirubin is a product of the body's metabolism of hemoglobin, the carrier
of oxygen in red blood cells. Disruption of the excretion of this component of bile
leads to a yellow discoloration of the eyes and skin (jaundice).
4. Protein and miscellaneous components
39
Bile production and recirculation is the main excretory function of the liver. Tumors that
obstruct the flow of bile from the liver can also impair other liver functions. Therefore, it
is necessary to understand these other functions to understand the symptoms that these
tumors can cause. These include:
Metabolic functions, such as the maintenance of glucose (blood sugar) levels
Synthetic functions, such as the synthesis of serum proteins such as albumin, blood
clotting (coagulation) factors, and complement (a mediator of inflammatory responses)
Storage functions, such as the storage of sugar (glycogen), fat (triglycerides), iron,
copper, and fat soluble vitamins (A, D, E, and K)
Catabolic functions, such as the detoxification of drugs
Circulation of the blood in blood vessels
There are two circulatory routes of blood
as it flows through the blood vessels: the
systemic and the pulmonary circulation. In
systemic circulation, blood flows from the left
ventricle of the heart through blood vessels to
all parts of the body (except gas exchange
tissues of lungs) and back to the atrium. In
pulmonary circulation on the other hand, venous
blood moves from the right atrium to right
40
ventricle to pulmonary artery to lung arterioles and capillaries where gases exchanged;
oxygenated blood returns to the left atrium via pulmonary veins; from left atrium, blood
enters the left ventricle.
Hepatic Portal Circulation
The veins of the hepatic
portal circulation drain the
digestive organs, spleen, and
pancreas and deliver this blood to
the liver through the hepatic portal
vein. When you have just eaten,
the hepatic portal blood contains
large amounts of nutrients. Since
the liver is a key body organ
involve in maintaining the proper
glucose, fat and protein concentrations in the blood, this system “takes a detour “to
ensure that the liver processes these substances before they enter the systemic circulation.
As blood flows slowly through the liver, some of the nutrients are removed to be stored
or processed in various ways for later release to the blood. The liver is drained by the
hepatic veins that enter the inferior vena cava. Like the portal circulation that links the
hypothalamus of the brain and the anterior pituitary gland, the hepatic portal circulation is
41
a unique and unusual circulation. Normally, arteries feed capillary beds, which in turn
drain into veins. Here we see veins feeding the liver circulation.
The inferior mesenteric vein, draining the terminal part of the large intestine,
drains into the splenic vein, which itself drains the spleen, pancreas and the left side of
the stomach. The splenic vein and superior mesenteric vein (which drains the small
intestine and the first part of the colon) join to form the hepatic portal vein. The L.
Gastric vein, which drains the right side of the stomach, drains directly into the hepatic
portal vein.
42
ETIOLOGY
43
Basic Etiology Present/ Rationale Actual
Absent
Predisposing
Factors
Male  Liver Cirrhosis occurs The patient is male.

mostly in men.
http://www.cancer.org/docr
oot/cri/content/cri_2_2_2x_
what_causes_liver_cancer_
25.asp
Ages 45-75  Liver Cirrhosis is most The patient is 72 years old.

common among people ages
45-75 years old.
Race: Asian  In Asia and Africa, cirrhosis The patient is an Asian since
is also common but more he was born from Filipino
likely to be associated with parents, and he was born in
hepatitis. IGACOS, Davao City, and
currently resides here in
http://esynopsis.uchc.edu/e
Buhangin, Davao City.
Atlas/GI/1210.htm
Biliary atresia X Infants can be born without The patient has no record or
bile ducts (biliary atresia) history of Biliary atresia.
and ultimately develop
cirrhosis. The bile ducts
carry bile formed in the
liver to the intestines, where
the bile helps in the
digestion of fat. So, when
the bile ducts are blocked,
bile is trapped in the liver,
http://www.medicinenet.co
44
m/cirrhosis/page3.htm
Basic Etiology Present/ Rationale Actual
Absent
Precipitating
Factors
Chronic  Chronic high levels of alcohol As stated by the

alcoholism consumption injure liver cells. patient’s wife, the
Alcohol seems to injure the liver patient at his young age
by blocking the normal was able to drink 1 long
metabolism of protein, fats, and neck (750 ml) of
carbohydrates. Alcohol can Tanduay on his own. At
poison all living cells, causing times, he goes beyond 1
liver cells to become inflamed long neck and even
and die. Thirty percent of drinks half a gallon of
individuals who drink daily at “Tuba” when he is not
least eight to sixteen ounces of yet drunk. As stated by
hard liquor or the equivalent for his wife, his husband
fifteen or more years will develop does not stop drinking
cirrhosis. unless he becomes
drunk. When he reached
http://www.emedicinehealth.com/
his adulthood, he
cirrhosis/page2_em.htm#Cirrhosi
continues to drink and
s%20Causes
smoke when he finds
time to do them.
Chronic viral X Condition where hepatitis B or The patient had no

hepatitis hepatitis C virus infects the liver medical record of
(types B, C, for years. some patients infected acquiring hepatitis B, C,
and D). with hepatitis B virus and most or D.
patients infected with hepatitis C
virus develop chronic hepatitis,
which, in turn, causes progressive
45
liver damage and leads to
cirrhosis, and, sometimes, liver
cancers.
Hepatitis B causes liver

inflammation and injury that over
several decades can lead to
cirrhosis. Hepatitis D is
dependant on the presence of
hepatitis B, but accelerates
cirrhosis in co-infection
The hepatitis C virus ranks with

alcohol as a major cause of
chronic liver disease and
cirrhosis. Infection with this virus
causes inflammation of and low
grade damage to the liver that
over several decades can lead to
cirrhosis.
http://www.spiritus-
temporis.com/cirrhosis/causes.ht
ml
46
Smoking  Research reveals that smoking The patient smokes 1-2
damages the liver. Smoking packs of cigarette a day,
activates chemical materials and he started smoking
within the body. These chemicals when he was a teenager.
that are manufactured by smoking At the same time, he
also provoke oxidative stress also drinks Tanduay
which is linked with lipid (750mL) 2-3 times a
peroxidation. When this occurs, week since he was a
the condition fibrosis is teenager. He only
developed. stopped smoking when
he was diagnosed with
Smoking increases the
hypertension last 2009.
manufacturing of pro-
inflammatory cytokines which is
related to liver cell damage.
Smoking also contributes the
continued succession of chronic
alcoholic-hepatitis as well as to
the progression of cirrhosis.
Http://www.ehow.com/how-
does_4577854_effects-smoking-
drinking-liver.html
47
Malnutrition, X Fat builds up in the liver and There is no scientific
especially eventually causes cirrhosis. basis that the patient has
high fat intake an increase fat in the
Fat (triglycerides) accumulates
blood or increased level
throughout the hepatocytes for the
of cholesterol in the
following reasons:
blood (LDL-bad
cholesterol)
• Export of fat from the
liver is decreased because
hepatic fatty acid
oxidation and lipoprotein
production decrease.
• Input of fat is increased
because the decrease in
hepatic fat export
increases peripheral
lipolysis and triglyceride
synthesis, resulting in
hyperlipidemia.
http://digestive.niddk.nih.gov/ddi
seases/pubs/cirrhosis/
48
SYMPTOMATOLOGY
SYMPTOMS Present/ Rationale Actual

absent
Anorexia  Increased brain tryptophan (TRP) This is present

availability for serotonin synthesis with the patient,
play a role in the pathogenesis of since this is one
anorexia. Since in chronic liver of the reasons he
failure, increased plasma and consulted the
cerebrospinal fluid TRP emergency room.
concentrations are characteristically The wife stated
reported, that also in liver cirrhosis, that the patient
increased brain TRP availability had no appetite to
constitute the pathogenic mechanism eat
of anorexia.
http://www3.interscience.wiley.com/j
ournal/49716/abstract?
CRETRV=1&SRETRY=0
Nausea and  The malabsorption of fats may lead Two weeks prior
vomiting to deficit of fatsoluble vitamins, to admission, the
hemorrhoids, intolerance to fatty patient started
foods, nausea and vomiting attacks, feeling nauseous,
and abdominal bloating. Since the and four days
liver has already decreased in prior to
function, its function to produce bile admission, he had
which emulsifies fats is also prandial vomiting
decreased, thus these symptoms which is one of
persists. the reasons he
49
www.enwikipedia.org/wiki/Liver_dis sought
ease#Symptoms_of_a_diseased_liver consultation at the
emergency room.
Body malaise  This is due to the decreased in liver The patient

function of the liver because of the experienced body
hepatic fibrosis. Therefore, the malaise, and was
patient has also decreased one of his chief
erythropoietin which then results to complaint that
the decrease of red blood cells resulted to his
circulating in the blood, and there admission at
will be decreased hemoglobin. All of DMC.
this in return will cause the patient to
have body malaise.
Bleeding  Bleeding tendencies such as The patient had

tendencies nosebleeds, easy bruising, and bleeding as
bleeding gums may result from evidenced by him
thrombocytopenia secondary to having black
splenomegaly, decreased vitamin K stools, which is
absorption and decreased production also known as
of coagulation factors and melena, indicative
regurgitation of blood to the spleen of bleeding in the
and gastrointestinal tract. upper
gastrointestinal
tract.
Suddarth, Doris Smith. The
Lippincott Manual of Nursing
Practice. 5th edition. 1991. Pages 514-
515.
Portal  Portal hypertension occurs because of The patient has
50
hypertension the obstruction of portal circulation ascites which is a
brought about by the portal complication of
obstruction caused by the hepatic portal
scarring. hypertension.
This is an
http://www.emedicinehealth.com/cirr
hosis/page2_em.htm#Cirrhosis evidence that he
%20Causes indeed has portal
hypertension. In
addition, the
patient was
diagnosed to have
hypertension on
the year 2009.
Ascites This happened because of the The patient has

decrease of albumin in the blood ascites as
plasma. Albumin is responsible for evidenced by his
maintaining the oncotic pressure in distended
the blood volume. A decrease in abdominal cavity.
albumin will mean a decrease in
oncotic pressure, which will result to
a more permeable membrane which
results to fluid leaking through the
vasculature into the abdominal
cavity.
Suddarth, Doris Smith. The

Lippincott Manual of Nursing
Practice. 5th edition. 1991. Pages 514-
515.
Jaundice  Jaundice is the buildup of bile The patient was

pigment that is passed by the liver noted to have
51
into the intestine. Due to the portal yellowish skin
obstruction, the bile going to the GI color on all four
tract will have a backflow to the extremities
liver. The bile then goes to the blood including the
stream, and this causes the yellowing palms. The
of the skin, due to the presence of bi patient also had
icteric sclera
(http://www.healthscout.com/ency/68
when inspected.
/292/main.html)
edema on the  Plasma albumin is reduced, leading One week prior to

extremities to edema. admission, the
wife of the patient
Suddarth, Doris Smith. The noticed the
Lippincott Manual of Nursing obvious
Practice. 5th edition. 1991. Pages 514- abdominal
515. distention of the
patient’s
abdomen. Upon
physical
assessment, the
patient was noted
to have ascites
and edema on all
four extremities.
Caput medusae  Portal hypertension results from the The patient was
abnormal blood flow pattern in liver noted to have
created by cirrhosis. The increased large, dilated, and
pressure is transmitted to collateral distended veins
venous channels. Sometimes these on the abdomen
venous collaterals are dilated. Caput area when
52
medusa consists of dilated veins seen inspected
on the abdomen of a patient with
cirrhosis of the liver.
Coma  This is a progressive symptom, The patient is on a

secondary to the loss of ammonia to comatose state.
urea conversion and consequent
delivery of toxic ammonia to the
brain.
Deterioration of mental function from
lethargy to coma and eventual death
PATHOPHYSIOLOGY
53
PATHOPHYSIOLOGY
54
DOCTOR’S ORDERS
DATE DOCTOR'S RATIONALE REMARKS
ORDER
Feb. 6, Please admit patient Admission in the hospital is required ADMITTED
2010 under blue service – for optimum medical and nursing care;
55
Level II CP Pavillion and to receive medications, undergo
tests, and perform procedures which
can only be done in the hospital setting.
The blue service accommodates
patients with gastro, endo and
immunologic problems.
VSq4 and record Vital signs are taken to provide TAKEN
please baseline data and to watch-out for any AND
unusualities. RECORDED
Start venoclysis with Helps expand intravascular volume, STARTED
PNSS 1L @ corrects an underlying imbalance in
120cc/hr fluids and electrolytes and compensates
the loss in the body. Moreover, it serves
as a route for medication.

Labs: CBC (complete blood count and DONE
CBC PC platelet count) is a basic screening test WITH
and is one of the most frequently RESULTS
ordered laboratory procedures. The
findings in the CBC PC give valuable
diagnostic information about the
hematologic and other body systems,
prognosis, response to treatment and
recovery.
CXR-PA A chest radiograph is used to diagnose DONE BUT
56
conditions affecting the chest, its NO
contents, and nearby structures. Chest IMPRESSIO
radiographs are among the most N MADE
common films taken, being diagnostic
of many conditions. A chest x-ray may
be ordered when a person's symptoms
include a persistent cough, coughing up
blood, chest pain, a chest injury, or
difficulty in breathing.
ECG ECG is a non-invasive test used to NOT DONE
assess the heart function. It is a
graphic produced by an
electrocardiograph, which records the
electrical activity of the heart over
time.
B1 B2 Elevation of serum bilirubin levels is DONE
related to hemolysis of RBCs and WITH
subsequent re-absorption of RESULTS
unconjugated bilirubin from the small
intestines. The condition may be
benign or may place the patient at risk
for multiple complications/untoward
effects.
57
BUN The BUN test is primarily used, along DONE
with the creatinine test, to evaluate WITH
kidney function in a wide range of RESULTS
circumstances, to help
diagnose kidney disease, and to
monitor patients with acute or
chronic kidney dysfunction or
failure. Increased BUN levels suggest
impaired kidney function. This may
be due to acute or chronic kidney,
damage, or failure.
S. Na, S. K Serum sodium and serum potassium NOT DONE
levels are checked to determine fluid
and electrolyte balance.

Crea A disorder in the kidney function NOT DONE
reduces excretion of creatinine,
resulting in increased blood creatinine
levels. This test diagnoses impaired
renal functions.
SGPT and SGOT Elevations of SGPT, an enzyme found DONE
within the liver cells, indicate that the WITH
liver cells are either leaky (internal RESULTS
contents are entering the blood) or
damaged.
58
Meds: Inhibits reabsorption of sodium and GIVEN
Furosemide 40 mg chloride at proximal and distal tubule
tab OD and in the loop of Henle

Spironolactone Spironolactone inhibits the action of GIVEN
25mg tab OD aldosterone thereby causing the kidneys
to excrete salt and fluid in the urine
while retaining potassium.

Essentiale Forte Increase functional status of the liver, GIVEN
CAP BID improvement in the lipids metabolism
caused by accelerated synthesis of
lipoproteins in the liver, activation of
the phospholipid-depending ferments,
increased synthesis of glycogen in the
liver, decreased the fatty infiltration of
the hepatocytes
I&O q shift Intake & output monitoring is done to RECORDED
assess the fluid retention status of the
patient and to prevent cardiac overload.

Watch out for any To ensure that immediate nursing WATCHED
unsualities interventions can be rendered in cases OUT
of deviances from the normal health
status so complications can be
prevented
Refer accordingly Referral is done to correct unusualities REFERRED
as soon as possible and to inform the
59
attending physician of the patient's
condition.
February Labs: CBC PC, These tests were not yet done and so NOT DONE
7, 2010 ECG, B1 B2, S. Na, the doctor ordered again and made
@ 4:00 K, Crea, SGPT, requests for these tests for analysis.
AM SGOT
Follow up chest X- This is to inform the patient or FOLLOWED
ray reading significant other to have the copy of the UP
result from the laboratory.

Additional labs: 1. Transabdominal USD is ordered to for NOT DONE
Transabdominal visualization of the abdomen which
USD helps in diagnosing the patient’s
condition.
2. Serum albumin A serum albumin test measures the DONE
amount of this protein in the clear WITH
liquid portion of the blood. This test RESULTS
can help determine if a patient
has liver disease or kidney disease, or
if the body is not absorbing
enough protein.
3. HBS-Ag The hepatitis B surface antibody (anti- NOT DONE
HBs) is the most common test. Its
presence indicates previous exposure
to HBV, but the virus is no longer
present and the person cannot pass on
60
the virus to others.
4. Anti-HAV IgM This test is used to help diagnose a NOT DONE
liver infection due to the hepatitis A
virus (HAV). This test may also be
used to determine if you have
produced antibodies and developed
immunity in response to a hepatitis A
vaccine or a previous hepatitis A
infection.
6. Anti-HCV To determine if you have contracted NOT DONE
the hepatitis C virus (HCV) and to
monitor treatment of the infection

7. PT/PTT Since the Prothrombin time (PT) NOT DONE
evaluates the ability of blood to clot
properly, it can be used to help
diagnose bleeding. When used in this
instance, it is often used in
conjunction with the PTT to evaluate
the function of all coagulation factors.
Occasionally, the test may be used to
screen patients for any previously
undetected bleeding problems prior to
surgical procedures.
61
Furosemide 40mg Inhibits reabsorption of sodium and GIVEN
IVTT now, then chloride at proximal and distal tubule
Furosemide 40mg 1 and in the loop of Henle
tab BID
Spironolactone Spironolactone inhibits the action of GIVEN
100mg BID aldosterone thereby causing the kidneys
to excrete salt and fluid in the urine
while retaining potassium.

Essentiale Forte 1 Increase functional status of the liver, GIVEN
cap TID improvement in the lipids metabolism
the hepatocyte
Lactulose 30cc @ Produces osmotic effect in colon. GIVEN
bedtime Resulting distention promotes
peristalsis. Decrease blood ammonia
buildup causes hepatic
encephalopathy, probably ass result of
bacterial degradation which lowers pH
of colon contents.
Ceftriaxone 1gm This antimicrobial agent inhibits GIVEN
62
IVTTq12, ANST bacterial cell wall synthesis by binding
to one or more of the penicillin-
binding proteins (PBPs) which in turn
inhibits the final transpeptidation step
of peptidoglycan synthesis in bacterial
cell walls, thus inhibiting cell wall
biosynthesis. Bacteria eventually lyse
due to ongoing activity of cell wall
autolytic enzymes (autolysins and
murein hydrolases) while cell wall
assembly is arrested.
Please monitor I&0 Intake & output monitoring is done to MONITORE
q shift and record assess the fluid retention status of the D
patient and to prevent cardiac overload.

Refer if UO < 30 A decrease in urine output may indicate REFERRED
cc/hr a serious, even life-threatening
condition. It may be caused by
dehydration du, diarrhea, lack of
adequate fluid intake or total urinary
tract obstruction.
CBG q6 (6AM- The capillary blood glucose test is NOT DONE
11AM- 6PM – ordered to measure the amount of
11PM) glucose in the blood right at the time
of sample collection. It is used to
63
detect
both hyperglycemia and hypoglycemia
, to help diagnose diabetes, and to
monitor glucose levels.

Refer if CBG ≥ High levels of glucose most frequently REFERRED
180mg/dL, < indicate diabetes, but many other
80mg/dL diseases and conditions can also cause
elevated glucose such as chronic renal
failure and hyperthyroidism. Low
blood glucose levels are seen in
patients with drinking alcohol and
extensive liver disease.

Refer Referral is done to correct unusualities REFERRED
condition.
February Please do gastric Gastric lavage is done to address DONE
7, 2010 lavage now until gastrointestinal bleeding.
@ 8:10 water is clear

Please insert FBC To monitor the intake and output of the INSERTED
AM
F16 and attach to patient. This may also avoid bladder
urobag distention.
64
Strict I&O Intake & output monitoring is done to MONITORE
monitoring and assess the fluid retention status of the D AND
record please patient and to prevent cardiac overload. RECORDED
NPO Temporarily For better visualization of the abdomen DONE
during the ultrasound

Shift IVF to D5NSS D5NSS restores sodium chloride deficit SHIFTED
1L @ 80cc/hr and extra cellular fluid volume.

For USD of the Abdominal ultrasound is an imaging NOT DONE
whole abdomen, procedure used to examine the
KUB, Pancreas presence of abnormalities in the
structure of the organs
intraabdominally.
Continue other meds All medications previously ordered by CONTINUE
attending physician should be D
continued to hasten patient's recovery.

Please attach all labs For monitoring and analysis of the ATTACHED
requested patient’s condition through the results
of the tests done

Feb. 8, Start omeprazole Suppress gastric acid secretion by STARTED
2010 @ 40mg IVTTq12, 1st inhibiting the partial cell H+/K+ ATP
6:20 AM done once available pump
*coffee-
ground
output /
NGT
65
Feb. 9, Repeat CBC, These tests were not yet done and so NOT DONE
2010 @ protime, USD of the the doctor ordered again and made
11:00 liver, Pancreas, requests for these tests for analysis.
AM serum albumin,
BUN
Lactulose 30cc TID, Produces osmotic effect in colon. GIVEN
to make 4-5 bowl Resulting distention promotes
mvt/day peristalsis. Decrease blood ammonia
buildup the causes hepatic
encephalopathy, probably ass result of
bacterial degradation which lowers pH
of colon contents.
Furosemide 40 mg Inhibits reabsorption of sodium and GIVEN
IVTT, OD chloride at proximal and distal tubule
and in the loop of Henle

Omeprazole 40mg Suppress gastric acid secretion by GIVEN
IVTT q12 inhibiting the partial cell H+/K+ ATP
pump
Vit. K 1 amp IVTT It is given to prevent bleeding. GIVEN
OD
Essential Forte 1 cap Increase functional status of the liver, GIVEN
TID improvement in the lipids metabolism
66
the hepatocytes
Metronidazole Disrupts DNA and protein synthesis GIVEN
500mg 1 TAB q6 susceptible organisms. Therapeutic
effects: Bactericidal, trichomonacidal
or amebicidal action. Spectrum: Most
notable for avtivity against anaerobic
bacteria including: Bacteroides,
clostridium. In addition is active
against: Trichomonas vaginalis,
entamoeba histolytica, giardia lamdia,
H. pylori and clostridium difficile.

Hold all PO Meds Holding all PO meds is done as DONE
preparation for the gastric lavage.
Giving medications would just be
drawn out of the patient’s stomach
during the procedure.

Pls. do gastric lavage Gastric lavage is done to address DONE
until gastric aspirate gastrointestinal bleeding.
goes out clear

NPO temporarily For better visualization of the abdomen DONE

CBG Monitoring q6 The capillary blood glucose test is NOT
ordered to measure the amount of MONITORE
67
glucose in the blood right at the time D
detect

Refer for persistent ↓ To notify the physician regarding the REFERRED
in sensorium changes of the patient’s health status
and to prevent further complications

Feb. 9, Restrain if necessary Patient may be restless or RESTRAINE
2010 @ (per watcher’s uncomfortable with the equipment D
12:05 request) attached to him needing a restraint to
PM keep them in place and prevent
dislodging causing harm.

Feb. 10, Repeat CBC Plt Ct, These tests were not yet done and so NOT DONE
2010 @ Protime with INR, the doctor ordered again and made
1PM Serum Na, K, Crea, requests for these tests for analysis.
ABG Blood gases are a measurement of DONE
how much oxygen and carbon dioxide
is in your blood. It also determines the
acidity (pH) of your blood. The test is
used to evaluate respiratory diseases
and conditions that affect the lungs. It
helps determine the effectiveness of
68
oxygen therapy. The test also provides
information about the body's
acid/base balance, which can reveal
important clues about lung and kidney
function and the body's general
metabolic state.
Please facilitate To conduct ultrasound testing to the FACILITAT
transport on USD patient which may be helpful in ED
test today determining other problems in the
patient’s health status

NPO temporarily For better visualization of the abdomen DONE

Give tranexamic Inhibits activation of plasminogen, GIVEN
acid 100mg IVTT q8 thereby preventing the conversion of
plasminogen to plasmin
Give Vit. K 1 amp It is given to prevent bleeding. GIVEN
now, OD
For gastric lavage This is to ensure that the patient would DONE
today without fail undergo the gastric lavage as it is
needed by the patient immediately on
the same day as per doctor’s request

NPO except meds Restrictions for any intake per orem DONE
except the medications is given for
better visualization of the abdomen
during the ultrasound and for patient’s
69
recovery through the therapeutic effects
of medicine.
Start albumin 25% To compensate for the decreased STARTED
50 cc q12 albumin levels which is responsible for
maintaining osmotic pressure inside the
blood vessels
BP monitoring qh To monitor changes in the blood MONITORE
until stable pressure which is significant in D
determining the patient’s status

Continue meds All medications previously ordered by CONTINUE

condition.
Feb, 10, Referred for ↓ Glasgow Coma Scale or GCS, is REFERRED
2010 sensorium, (E1 V3 neurological scale which aims to give
M5) GCS 9 a reliable, objective way of recording
CR – 90 the conscious state of a person, for
RR – 22 initial as well as subsequent
T- 39 assessment. (E1 – does not open eyes,
V3- Utters inappropriate words, M5 -
Localizes painful stimuli) Moderate
Brain Injury, GCS 9 – 12
70
Do ABG now Blood gases are a measurement of DONE
how much oxygen and carbon dioxide
is in your blood. It also determines the
acidity (pH) of your blood. The test is
used to evaluate respiratory diseases
and conditions that affect the lungs. It
helps determine the effectiveness of
oxygen therapy. The test also provides
information about the body's
acid/base balance, which can reveal
important clues about lung and kidney
function and the body's general
metabolic state.
Do CBG now The capillary blood glucose test is NOT DONE
ordered to measure the amount of
glucose in the blood right at the time
detect

O2 inhalation @ 5-7 O2 inhalation is indicated for patients DONE
L/min via face mask that lack oxygen supply and need
assistance in maintain the desired
71
oxygen supply
Monitor VS qh and The patient is for close monitoring and MONITORE
record needs further assessment to monitor to D
address if there’s any unusualities

condition.
Feb. 11, Follow-up requested For monitoring and analysis of the FOLLOWED
2010 labs patient’s condition through the results -UP
of the tests done

For gastric lavage Gastric lavage is done to address DONE
gastrointestinal bleeding. Cold water
is used to prevent any bleeding in the
gastrointestinal tract.
IVF of PNSS 1L @ Helps expand intravascular volume, DONE
80cc/hr corrects an underlying imbalance in
fluids and electrolytes and compensates
the loss in the body. Moreover, it serves
as a route for medication
PNSS is isotonic with the blood and
tissue fluid, used as a solvent for drugs
that are to be administered parenterally
72
like blood to replace body fluids. It is
used as a prime once on blood
transfusion.
condition.
Feb. 11, Referred due to dec. Glasgow Coma Scale or GCS, is REFERRED
2010 sensorium GCS5 (E1 neurological scale which aims to give
(+) V1 M3) & dyspnea a reliable, objective way of recording
active the conscious state of a person, for
bleeding initial as well as subsequent
per orem assessment. E1- Does not open eyes,
V1 - Makes no sounds, M3 -
(+) gross Abnormal flexion to painful stimuli
hematuri (decorticate response), GCS of 5 –
a on FC Severe Brain Injury

Intubate pt. now The ET tube is inserted into a INTUBATE
with ET size 75 level patient's trachea in order to ensure that D
21 the airway is not closed off and that air
is able to reach the lungs. The
endotracheal tube is regarded as the
most reliable available method for
protecting a patient's airway.It is
73
indicated when the oxygenation with
noninvasive methods is inadequate
CAB while awaiting This is to provide the patient with DONE
mech. vent. Support adequate oxygen supply through
continues bag valving until the
mechanical ventilation support is
available.
MV Set-up To assist the patient in his breathing DONE
PO2 = 100% pattern since he is not able to support
RR 16 his own required oxygen levels.
TV 500cc
Insert NGT French Nasogastric intubation is a medical INSERTED
16 and open to drain process involving the insertion of a
plastic tube (nasogastric tube, NG
tube) through the nose, past the
throat, and down into the stomach.
The main use of a nasogastric tube is
for feeding and for administering
drugs and other oral agents.

NPO Temp For better visualization of the abdomen DONE

acid 500mg IVTT thereby preventing the conversion of
plasminogen to plasmin
74
Vit. K 1amp IVTT It is given to prevent bleeding. GIVEN
now – hold
Suction catheter – To remove retained secretion in the SUCTIONE
PRN catheter to clear obstructed airway D

Turn to sides q2 Turning the patient to sides prevents DONE
the patient from developing decubitus
ulcer.
Continue meds All medications previously ordered by CONTINUE

condition.
Feb. 11, Transfer to CP6 or 9 To provide better care and monitoring TRANSFER
2010 @ awaiting for ICU to the patient while awaiting for room RED
12NN vacancy vacancy in the ICU

For referral to For co-management and thorough INFORMED
consultant c/o Dr. analysis of the patient’s condition.
Honcoda today
To receive 2U PRBC In order to increase the number of red TRANSFUS
and transfuse once blood cells in the blood ED
available
To secure 6U FFP For the treatment of deficiencies of SECURED
and transfuse once coagulation proteins for which specific
available factor concentrates are unavailable or
75
undesirable.
acid 500mg IVTT thereby preventing the conversion of
q8, 1 dose now plasminogen to plasmin

For gastric lavage Gastric lavage is done to address DONE
with cold water gastrointestinal bleeding. Cold water
is used to prevent any bleeding in the
gastrointestinal tract.
Referral to Dr. For co-management and thorough REFERRED
Pilapil analysis of the patient’s condition.

For HBS-AG, Anti- These tests were not yet done and so NOT DONE
HBC IgM, Anti- the doctor ordered again and made
HCV requests for these tests for analysis.

For USD of the Abdominal ultrasound is an imaging NOT DONE
whole ABD procedure used to examine the
presence of abnormalities in the
structure of the organs
intraabdominally.
Pls. facilitate transfer To provide better care to the patient in FACILITAT
to IMCU/ICU a setting where he will monitored ED
thoroughly.
Feb. 11, Paracetamol 300mg Inhibits the synthesis of prostaglandins GIVEN
2010 @ IVTT now that may serve as mediators of pain and
12:45P fever, primarily in the CNS.
76
M Refer Referral is done to correct unusualities REFFERED
T – 38.2 attending physician of the patient's
condition.
Feb. 12, Dx: HBS-Ag, Anti- These tests were not yet done and so DONE
2010 @ HBC, Anti-HCV the doctor ordered again and made
11:45 requests for these tests for analysis.

Still for mech. vent. To provide the patient with adequate DONE
AM
Support amount of oxygen
Follow up For compatibility testing. FOLLOWED
crossmatching of Crossmatching is important to detect -UP
blood and transfuse agglutination of donor RBC’s caused
once available by antibodies in patient's serum.

For compliance to Continuation of medication ensure INFORMED
medication spontaneous treatment of patients
condition and compliance to the
medical regimen, revealing the desired
outcomes
condition.
77
DIAGNOSTIC EXAMS
Arterial Blood Gas
Arterial Blood Gas Test is done to determine an imbalance in the amount of oxygen gas (O2) or carbon dioxide gas
(CO2) in your blood or an acid-base imbalance, which may indicate a respiratory (lung/breathing), metabolic, or kidney
disorder. Blood gas tests are ordered when there are symptoms of an O2/CO2 or pH imbalance, such as difficulty breathing or
shortness of breath.
Date ordered: February10, 2010
Value Normal Range Unit Clinical Significance
pH 7.510 7.35-7.45 mmHg Increase in pH is brought about by the increase in bilirubin in the blood
which is alkalinic.
pC02 21.3 35-45 mmHg Decreased pC02 is caused by hypoxia due to the accumulated fluid in the
abdominal cavity creating pressure in the diaphragm. Thus, affecting the
respiratory status of the patient.
PO2 82.0 80-100 mmHg PO2 level is at normal range.
78
HC03 16.6 22.0-27.0 mmol/L When bicarbonate levels are lower than normal, it suggests that the body
is having trouble maintaining its acid-base balance. Bicarbonate
concentrations in the serum may fall due to consumption by combining
with protons (H+) from acids such as lactic acid, keto-acids etc; or by
loss from the body from gastro-intestinal or renal sources. Renal loss of
bicarbonate may be due to compensatory mechanisms for a respiratory
alkalosis.
02Sat 97.2% 80-100 % 02 Saturation is at normal range.
Partially Compensated Respiratory alkalosis
Respiratory alkalosis is a medical condition in which increased respiration (hyperventilation) elevates the blood pH (a
condition generally called alkalosis). Respiratory alkalosis is due to the dyspnea caused by the pressure exerted by the ascites
to the diaphragm, leading to respiratory rate which is lower than normal. Moreover, respiratory alkalosis could result from a
ventilatory rate or tidal volume that is too high or from the patient triggering excessive additional breaths.
79
Nursing Responsibilities when withdrawing blood
o Verify order and patient identity
o Explain to the patient the purpose of the hematology or blood test.
o Gather equipment and wear clean gloves
o Inform the patient that the blood sample will be drawn from his antecubital vein in either of the arms.
o Apply hot or cold compress to injection site if swelling occurs.
o Inform the patient that a total of 5cc of blood will be extracted from him.
o Label the sample and maintain chain of custody and deliver or send sample to the lab
o Properly dispose of used equipment
80
Hematology
Hematology is the study of blood and its disorders. Hematologists, board-certified internists, look specifically at blood
components such as blood count, and blood and bone marrow cells. Hematology tests can help diagnose anemia, hemophilia,
blood-clotting disorders, and leukemia.
Date ordered: February 6, 2010
81
TEST RATIONALE REFERENCE RESULT N/H/L CLINICAL SIGNIFICANCE
RANGE
CBC+PLT
Hgb Hemoglobin is the protein molecule 115-175 g/L 104 L Low hemoglobin is referred to
in red blood cells that carries oxygen as anemia which may by the
from the lungs to the body's tissues decreased erythropoietin caused by
and returns carbon dioxide from the cirrhosis of the liver.
tissues to the lungs. Hemoglobin also
plays an important role in maintaining
the shape of the red blood cells.

Hct Hematocrit is a measure of how much 0.36-0.52 0.29 L Because of the decrease in the RBC
space red blood cells take up in the in the blood, hematocrit as well
blood. would decrease.
RBC count RBC count is the number of red blood 4.20-6.10 2.94 L A decreased number of RBCs results
cells per volume of blood, and is x106 /uL from the decrease erythropoietin
reported in either millions in a production of the liver.
microliter or millions in a liter of
blood.
WBC count Measures the amount of white blood 5.0-10.0 x103 9.65 N WBC is in normal range.
cells. These immune cells form in /uL
the bone marrow to help fight
infection
82
DIFFERENTIAL COUNT
83
TEST RATIONALE REFERENCE RESULT N/H/L CLINICAL SIGNIFICANCE
RANGE
CBC+PLT
Hgb Hemoglobin is the protein molecule 115-175 g/L 107.0 L Low hemoglobin is referred to
in red blood cells that carries oxygen as anemia which may by the
from the lungs to the body's tissues decreased erythropoietin caused by
and returns carbon dioxide from the cirrhosis of the liver.
tissues to the lungs. Hemoglobin also
plays an important role in maintaining
the shape of the red blood cells.

Hct Hematocrit is a measure of how much 0.36-0.52 0.31 L Because of the decrease in the RBC
space red blood cells take up in the in the blood, hematocrit as well
blood. would decrease.
RBC count RBC count is the number of red blood 4.20-6.10 3.08 L A decreased number of RBCs results
cells per volume of blood, and is x106 /uL from the decrease erythropoietin
reported in either millions in a production of the liver.
microliter or millions in a liter of
blood.
WBC count Measures the amount of white blood 5.0-10.0 x103 12.78 H High levels indicate presence of
cells. These immune cells form in /uL bacterial infection.
the bone marrow to help fight
infection
84
DIFFERENTIAL COUNT
85
Blood Chemistry
Blood chemistry is the chemical composition of the blood. The levels of various substances in the blood can provide
clues to a patient's condition, ranging from the presence of a liver disorder to a pregnancy. Routine bloodwork to check blood
chemistry is often a part of a diagnostic workup, with the blood being analyzed to check for specific elements which could
contribute clues to the diagnosis. Doctors rely on information about normal ranges of things like proteins and lipids to read the
blood analysis.
TEST RESULT UNIT NORMAL L/N/H CLINICAL SIGNIFICANCE
RANGE
TOTAL PROTEIN 59.40 g/L 63 - 82 L Low total protein levels can
suggest a liver disorder. In
Total protein measurements can reflect patients with liver problems,
nutritional status and may be used to there is a decrease in total
screen for and help diagnose kidney protein levels because of the
disease, liver disease, and many other decrease in production of
conditions albumin, a protein which is
86
exclusively produced in the
liver.
GLOBULIN 40.70 g/L 23 - 35 H An elevation in the level of
serum globulin can indicate the
Globulins are proteins that include presence of cirrhosis of the liver
gamma globulins (antibodies) and a and bacterial infection.
variety of enzymes and carrier/transport
proteins.
They are a diverse group of proteins in
the blood, and together represent the
second most common proteins in the
bloodstream.
ALBUMIN 18.70 g/L 35 - 50 L There is a decrease of albumin
in the blood plasma because of
Albumin is the most abundant protein the decrease in its production
found in blood plasma, representing 40 due to problems in the liver.
to 60% of the total protein.

A/G RATIO 0.5 - 1.5 – 2.5 L A decrease in Albumin
87
Globulin Ratio is an indicative
The ratio of the concentrations of of a problem in liver functions.
albumin to globulin in blood serum.
88
Blood Chemistry
89
Result Unit Reference Ranges L/N/H Clinical Significance
SGPT 84.0 U/L 30.0-65.0 H An increase in SGPT level is due to impaired
liver function caused by liver cirrhosis. It can be

ALT (SGPT) is, by
caused by hepatic inflammation (including
contrast, normally found
infectious mononucleosis, pancreatitis, alcohol,
largely in the liver. This
viral hepatitis)
is not to say that it is
exclusively located in
liver but that is where it
is most concentrated. It is
released into the
bloodstream as the result
of liver injury. It
therefore serves as a
fairly specific indicator
of liver status.
SGOT 182.0 U/L 15.0-37.0 H An increase in SGPT level is due to impaired
liver function caused by liver cirrhosis. It can be
AST (SGOT) is normally caused by hepatic inflammation (including
found in a diversity of infectious mononucleosis, pancreatitis, alcohol,
tissues including liver, viral hepatitis)
heart, muscle, kidney, 90
and brain. It is released

91
DRUG STUDY
Deneric Name
Furosemide
Brand Name Furoside, Lasix Myrosemide, Uritol, Diumide-K®
Classification (functional) Loop diuretic
(chemical) Sulfonamide derivative

Dosage and Route 40 mg tab OD
Mechanism of Inhibits reabsorption of sodium and chloride at proximal and distal tubule
Action and in the loop of Henle

Indication Pulmonary edema, hypertension, third spacing
Contraindication Hypersensitivity to sulfonamides, anuria, hypovolemia, infants, lactation
and electrolyte depletion

Drug Interaction >increased toxicity with lithium, non-depolarizing skeletal muscle relaxant
>increased hypotensive action with antihypertensives and nitrates
>increased ototoxicity with aminoglycosides, cisplatin, vancomycin

Side/Adverse CNS: headache, fatigue, weakness, vertigo
Effects CV: orthostatic hypotension, chest pain, ECG changes circulatory collapse
EENT: loss of hearing, ear pain, tinnitus and blurred vision
ELECT: hypokalemia, hypochloremic alkalosis, hypocalcemia, matabolic
alkalosis
GI: nausea, diarrhea, dry mouth, abdominal cramps, gastric irritaions
GU: polyuria, renal failure, glycosuria
HEMA: thrombocytopenia, agranulocytosis, anemia
INTEG: rash, pruritus, purpura, diaphoresis

Nursing >assess for drowsiness and restlessness for it may indicate metabolic
Responsibilities alkalosis
>monitor for signs of hypokalemia; postural hypotension, malaise, fatigue,
tachycardia, leg cramps and weakness
>observe hearing problems including tinnitus and hearing loss
>monitor I & O qd to determine fluid loss.
>monitor vital signs; rate, depth, and rhythm of respiration
>administer in AM to avoid interference with sleep if using drug as diuretic
> Use sterile equipment and apply principles of asepsis.
> Ensure correct identification of the patient prior to the procedure.
>Decontaminate hands prior to the procedure.
>The cannula insertion site should be inspected for complications, i.e.
infiltration, infection.
>instruct patient to increase fluid intake 2-3 L/day unless contraindicated
>tell the patient to rise slowly from lying or sitting position because
orthostatic hypotension may occur
>evaluate for therapeutic response

Generic Name Omeprazole
Brand Name Losec and Prilosec
Photo
Classification Gastric acid secretion, proton-pump inhibitor

Dosage and Route 40mg IVTTq12
Mechanism of Suppress gastric acid secretion by inhibiting the partial cell H+/K+
Action ATP pump

Indication To prevent ulceration in patients under NPO
Contraindication Known hypersensitivity to omeprazole
Drug Interaction decreased effect: decreased ketoconazole; decreased itriconazole
increased toxicity: diazepam increase half-life; increased digoxin,
increased phenytoin, increased warfarin

Side/Adverse EffectsCNS: headache, dizziness
Neuromascular & Skeletal: weakness, back pain
GI: nausea, diarrhea, vomiting, abdominal pain, constipation, taste
perversion
Respiratory: upper respiratory infection, cough

Nursing  Ensure ten rights of medication administration
Responsibilities  Instruct patient not to chew, crush or open capsule
 Instruct patient to take before eating, capsule should be
swallowed whole
 Warn patients that Zegerid contains 460 mg sodium
bicarbonate per dose. Those following a sodium-restricted
diet should be cautious.
 Tell patient to empty contents of Zegerid packet into a small
cup containing 2 tablespoons of water.
 Instruct patient to take drugs 30 minutes before meals.
 Caution patient to avoid hazardous activities if he gets dizzy.
 Inform patient that prilosec OTC may take 1-4 days for full
effect.
Generic Name Spironolactone
Brand Name Aldactone
Photo
Classification Electrolyte and water balance agent; potassium sparing diuretic
Dosage and Route PO – (25, 50, 100) mg tablets
DOSING: Edema – 25 – 200 mg/d in divided doses, continued for

atleast 5 daysd
Mechanism of One of the main functions of the kidneys is to retain salt (sodium
Action chloride) and water in the body. In patients with heart failure and
cirrhosis, increased levels of a hormone produced by the adrenal
glands, called aldosterone, causes salt and fluid to be retained by the
kidneys. (At the same time, it also causes the kidneys to eliminate
potassium.) The body becomes overloaded with salt and water, and
this worsens the heart failure. Spironolactone inhibits the action of
aldosterone thereby causing the kidneys to excrete salt and fluid in
the urine while retaining potassium. Therefore, spironolactone is
classified as a potassium-sparing diuretic, a drug that promotes the
output of urine (diuretic) while allowing the kidneys to hold onto
potassium.
Indication clinical conditions associated with augmented aldosterone
production, as in essential hypertension, refractory edema due to
CHF, hepatic cirrhosis, nephritic syndrome and idiopathic edema
Contraindication Patients with anuria, acute renal insufficiency, significant
impairment of renal excretory function, or hyperkalemia.

Drug Interaction Spironolactone can lower blood sodium levels while raising blood
potassium levels. Excessively high blood potassium levels can lead
to potentially life-threatening abnormalities in the rhythm of the
heart. Therefore, spironolactone usually is not administered with

Generic Name Ceftriaxone
Photo
Brand Name Rocephin
Classification cephalosporin antibiotic
Dosage and Route 1gm IVTTq12
Mechanism of This antimicrobial agent inhibits bacterial cell wall synthesis by
Action binding to one or more of the penicillin-binding proteins (PBPs)
which in turn inhibits the final transpeptidation step of
peptidoglycan synthesis in bacterial cell walls, thus inhibiting
cell wall biosynthesis. Bacteria eventually lyse due to ongoing
activity of cell wall autolytic enzymes (autolysins and murein
hydrolases) while cell wall assembly is arrested.
Indication Respiratory tract and intraabdominal infections
Contraindication Cephalosporin hypersensitivity.
Drug Interaction Warfarin (Coumadin, Jantoven)
If you are taking ceftriaxone and warfarin, your body may
metabolize the drugs differently than intended. You healthcare
provider may choose to monitor your INR and prothrombin time
more frequently and adjust accordingly. INR and prothrombin
time are tests used to measure how well your blood clots.
Probenecid (Benemid, Probalan)
If you are taking both ceftriaxone and probenecid, your body
may metabolize the drugs differently than intended and
significantly increase the amount of ceftriaxone in your system.
Your healthcare provider may choose to monitor your progress

Generic Name metronidazole
Photo
Brand Name Flagyl
Classification Anti-infectives, antiprotozoals, antiulcer agents
Dosage and Route 500mg 1 TAB q6
Mechanism of Disrupts DNA and protein synthesis susceptible organisms.
Action Therapeutic effects: Bactericidal, trichomonacidal or amebicidal
action. Spectrum: Most notable for activity against anaerobic
bacteria including: Bacteroides, clostridium. In addition is active
against: Trichomonas vaginalis, entamoeba histolytica, giardia
lamdia, H. pylori and clostridium difficile.
Indication PO: Amebecide in the management of amebic dysentery, amebic
liver abscess and trichomoniasis: treatment of peptic ulcer
disease caused by Helicobacter pylori.
Contraindication Hypersensitivity.
Use cautiously in: history in blood dyscrasias, History of seizures
or neurologic problems and severe hepatic impairement.
Drug Interaction Drug-drug: Cimetidine may decrease metabolism of
metronidazole. Phenobarbital and rifampin increases metabolism
and may decrease effectiveness. Metronidazole increases the
effects of phenytoin, lithium, and warfarin. Disulfiram-like
reaction may occur with alcohol ingestion. May cause acute
psychosis and confusion with disulfiram. Increased risk of
leucopenia with fluorourousel or azathioprine.
Side/Adverse Effects CNS: Seizures, dizziness, headache.

Generic Name Lactulose
Photo
Brand Name Contulose
Classification Laxative
Dosage and Route 30cc @ bedtime
Mechanism of Produces osmotic effect in colon. Resulting distention promotes
Action peristalsis. Decrease blood ammonia buildup the causes hepatic
encephalopathy, probably ass result of bacterial degradation
which lowers pH of colon contents. Relieves constipation,
decreases ammonia concentration.
Indication - constipation
- To prevent and treat hepatic encephalopathy, including hepatic
precoma and coma I patients with severe hepatic disease.
- to restore bowel movements after hemorrhoidectomy.
Contraindication Contraindicated in patients on low- galactose diet
Drug Interaction Drug-drug.
- Should not be used with other laxatives in the treatment of
hepatic encephalopathy
- Anti- infectives may diminish effectiveness in treatment of
hepatic encephalopathy
Side/Adverse Effects GI: belching, cramps, distention, flatulence, diarrhea
ENDO: Hyperglycemia
Nursing
Generic Name Essentiale Forte
Photo
Brand Name Essential Forte
Classification Cholagogues, Cholelitholytics & Hepatic Protectors
Dosage and Route 1 cap TID
Mechanism of Increase functional status of the liver, improvement in the lipids
Action metabolism caused by accelerated synthesis of lipoproteins in the
liver, activation of the phospholipid-depending ferments,
increased synthesis of glycogen in the liver, decreased the fatty
infiltration of the hepatocytes
Indication - cirrhosis
- Hepatic steatosis (also in cases of diabetes)
- Acute and chronic hepatitis
- Necrosis of the liver cells
- Hepatic coma and precoma
- Toxic liver damage (including pregnancy toxicosis)
Contraindication - Contraindicated in patients hypersensitive to drug
-in newborn children
-in pregnant women
Drug Interaction Not indicated
Side/Adverse Effects In very rare cases it can cause :abdominal pain, nausea, diarrhea
and allergic reaction(skin rash).
Nursing 1. Instruct patient on proper use of the drug

Responsibilities
Generic Name Phytonadione
Photo
Brand Name Aqua-Mephyton, Vitamin K
Classification Vitamin ( fat soluble)
Dosage and Route 1 amp now, OD
Mechanism of -Required for hepatic synthesis of blood coagulation factors II
Action (prothrombin), VII, IX, and X.
- prevention of bleeding due to hypoprothrombinemia
Indication • Anticoagulant-induced prothrombin deficiency caused by
coumarin or indanedione derivatives;
• Prophylaxis and therapy of hemorrhagic disease of the
newborn;
• hypoprothrombinemia due to anti-bacterial therapy;
• hypoprothrombinemia secondary to factors limiting
absorption or synthesis of vitamin K, e.g., obstructive
jaundice, biliary fistula, sprue, ulcerative coilitis, celiac
disease, intestinal resection, cystic fibrosis of the
pancreas, and regional enteritis;
• other drug-induced hypoprothrombinemia.

Contraindication Hypersensitivity to any component of this medication.
Drug Interaction -Large doses will counteract the effect of warfarin
- large doses of salicylates or broad-spectrum

Generic name paracetamol
Photo
Brand name Aeknin
Classification Therapeutic: antipyretics, non-opiod analgesics
Ordered Dosage and 300mg IVTT now
Frequency
Mode of Action Inhibits the synthesis of prostaglandins that may serve as
mediators of pain and fever, primarily in the CNS. Has no
a significant anti-inflammatory property or GI toxicity.
Therapeutic Effects: analgesia, antipyresis.
Indication Mild pain, Fever
Contraindication Contraindicated in: Previous hypersensitivity. Products
containing alcohol, aspartame, saccharin, sugar, or
tartrazine should be avoided in patients who have
hypersensitivity or intolerance to these compounds.
Used cautiously in: Hepatic disease/renal disease; chronic
alcohol use/abuse; Malnutrition
Drug Interactions Drug-drug: Chronic high-dose acetaminophen may
increase the risk of bleeding with warfarin. Hepatoxicity is
additive with other hapatotoxic substances, including
alcohol.
Adverse Reactions/ GI: Hepatic failure, hepatoxicity (overdose)
Side Effects
GU: renal failure(high doses/chronic use)
Hemat: neutropenia, pancytopenia, leukopenia

Generic name Tranexemic acid
Photo
Brand name Cyclokapron
Classification Hemostatic agent, antifibronolytic agent
Ordered Dosage and 100mg IVTT q8
Frequency
Mode of Action Inhibits activation of plasminogen, thereby preventing the
conversion of plasminogen to plasmin
Indication Prevention of hemorrhage
Contraindication Hypersensitivity, active intravascular clotting
Drug Interactions Concurrent use of clotting factor, complexes may increase
the risk of thrombotic complications. risk of thrombosis may
be increased by estrogens. Drug will antagonize the effects
of thrombolytic agents.
Adverse Reactions/ CNS: visual abnormalities
Side Effects
CV: hypotension, thrombosis, thromboembolism
GI: nausea, vomiting, diarrhea
Nursing i. observe the 10 rights of medication
Responsibilities administration of medication
ii. check for hypersensitivity to drug
iii. observe for bleeding
iv. instruct patient ot take tranexamic acid
as directed
NURSING THEORIES
Theorist: Dorothea Orem
Theory: Self-care Deficit Theory
Orem’s theory states that each person has a need for self care in order to maintain
optimal health and wellness. Each person possesses the ability and responsibility to care
for themselves and dependants. The theory is separated into three conceptual theories
which include: self-care, self-care deficit, and nursing system. Self care is the ability to
perform activities and meet personal needs with the goal of maintaining health and
wellness of mind, body and spirit. Self-care is a learned behavior influenced by the
metaparadigm of person, environment, health and nursing. There are three components of
this theory: universal self-care needs, developmental self-care needs, and health
deviation. Universal theory includes activities which are essential to health and vitality.
Developmental self-care need include the interventions and teachings designed to return
to a person to or sustain a level of optimal health and well-being. Health Deviation self-
care encompasses the variation of meeting self-care which may occur as a result of
disability, illness or injury. Orem created three areas of how care can be administrated to
a client depending on the physical and mental capabilities of the client: the wholly
compensatory, partly compensatory and the supportive-educative role. The wholly
compensatory system accomplishes the client’s therapeutic self-care, compensates for the
client’s inability to participate in their self-care, provides support and protects the client.
The partly compensatory is a give and take system between the client and the nurse. The
nurse performs, compensates and assists the client as needed while the client participates,
regulates and accepts care and assistance form the nurse. Lastly, the supportive-educative
role indicates that the client is participating in most of their self-care, and the nurse’s role
is simply to monitor and regulate the client’s self-care.
Application to client:
The client’s environment failed to provide adequate warmth and ventilation. It
has a limited space and is not quiet enough for the client to take adequate rest. These
factors contributed to the client’s present condition as well as his ability to cope and
recover. The nurse’s role is to help client achieve optimal health and wellness by acting
as an advocate, redirector, support person and teacher and to provide an environment
conducive to therapeutic development. One example of this theory is by creating nursing
care plans which was made by the student nurses. The theory applies to the assessment
and evaluation of the nursing process.
Since patient is in a comatose state, we have applied the wholly compensatory
system. Since patient is unable to do the self-care activities, the nurse together with the
medical team assisted the client’s needs by providing adequate care to the patient
through helping the client achieve good hygiene, preventing bed sore by turning the
patient to sides, preventing injury and promoting rest and comfort to the patient. Also,
nurses were able to create nursing care plans which became their guide on how to
render care to the patient. Also, important health teachings were provided to the family
of the patient.
Theorist: Lydia Hall
Theory: Core, Care and Cure Theory
Hall's theory emphasizes the importance of individuals as unique, capable of
growth and learning, and requiring a total person approach. Her definition of health can
be inferred to a state of self-awareness with conscious selection of behaviors that are
optimal for that individual. Hall stresses the need to help the person explore the meaning
of his or her behavior to identify and overcome problems through developing self-identity
and maturity. The concept of society or environment is dealt with in relation to the
individual. Hall's theory of nursing involves three interlocking circles, each one of it
represents one aspect of nursing. The same aspect represents intimate bodily care of the
patient. The core aspect deals with the innermost feeling and motivations of the patient
and family through the medical aspects of care.
Care is the sole function of nurses, where as core and cure are shared with other
members of the health care team. The major purpose of care is to achieve interpersonal
relationship with the individual. The nurse plans and prepares a series of independent
nursing interventions that can aid from its condition. These interventions are designed to
provide good and conducive atmosphere, administering drugs to the right patient, right
drug and right time. The nurse also provides health teachings to the client’s family on
medication management and independent actions such as advising the client to have
complete bed rest.

Theorist: Faye Glenn Abdellah
Theory: Twenty-one Nusring Problems
Abdellah’s theory would state that nursing is the use of the problem solving
approach with key nursing problems related to health needs of people. Such a statement
maintains problem solving as the vehicle for the nursing problems as the client is moved
toward health – the outcome. Faye Abdellah formulated the twenty-one Nursing
Problems and categorizes them into three: the Physical, sociological, and emotional needs
of clients, the types of interpersonal relationships between the nurse and patient and the
common elements of client care. The 21 Nursing Problems were divided into four care
needs: Basic to all patients, Sustenal care needs, Remedial care needs and Restorative
care needs.
The Nursing problem presented by a client is a condition faced by the client or
client’s family that the nurse through the performance of professional functions can assist
them to meet. An overt nursing problem is an apparent condition faced by the patient or
family, which the nurse can assist him or them to meet through the performance of her
professional functions. The covert nursing problem is a concealed or hidden condition
faced, by the patient or family, which the nurse can assist him or them to meet through
the performance of her professional functions. According to Abdellah, nursing is a
helping profession.
Application to Client:
Since our patient is suffering from his condition, the student nurses have identified
nursing problems which made them choose the theory of Abdellah. The patient was in a
state of coma and so he was not able to perform certain activities which he needs. Thus,
student nurses provided care and assisted the client and his family. Some of the nursing
interventions done to address the problems identified by the student nurses which falls
under the 21 nursing problems theory were: maintained good hygiene and physical
comfort, promoted rest and sleep, promoted safety through the prevention of accidents,
injury, or other trauma and through the prevention of the spread of infection, maintained
good body mechanics and prevent and correct deformity, To facilitate the maintenance of
a supply of oxygen to all body cells, facilitated the maintenance of elimination, recognize
the physiological responses of the body to disease conditions, created and / or
maintained a therapeutic environment. The student nurses focused their interventions to
the needs of the patient which helps in the promotion of recovery to the patient.
NURSING CARE PLANS
Date / Cues Needs Nursing Diagnosis Objective of Nursing Intervention Evaluation

Time Care
February Objective: A Ineffective airway At the end of 1. Provide suctioning. February 11,
11, 2010 at clearance related to 7 hours span 2010; 11pm
- crackles C R: to clear airway from accumulated
accumulation of of care, the
4pm heard on lung secretions. GOAL UNMET
T secretions secondary patient will
field upon
to Community have 2. Elevate head of bed. After rendering
ausculatation I
Acquired Pneumonia effective nursing
R: Gravity decreases pressure on the
-with bag V airway as interventions
diaphragm
valve evidenced by within the
I
connected to R: Pneumonia, which absence of 3. Turn patient to sides every 2 hours 7hours span of
endotracheal T is an acute infection crackles. care, the patient
R: repositiong enhances drainage and
tube of the lungs, causes has still
Y promotes ventilation to different lung
inflammation in lung ineffective
segments.
- tissues which leads to airway clearance
damage on mucous 4. Assist in providing respiratory as evidenced by
E
and alveolar support through ambu bagging. presence of
X membranes. This crackles on lung
R: mechanical ventilation maintains
damage results in field.
E adequate airways and improve
secretion of exudates
respiratory functions.
and mucous as the
R system tries to get rid 5. Insert mouth guard.
with the infection.
C R: to maintain anatomic position of
This secretions cause
the tongue and provide natural airway
I obstruction in the
airway. 6. Re-ausculate lung sound
S
R: to note for progress, if crackles are
E
still present.
Williams, L.S &
P
Hoppers, P.D. (2007). 7. Provide oxygen with appropriate
A Understanding humidifier, as ordered.
medical-surgical
T R: to facilitate oxygenation and
nursing,3rd ed.
liquefy secretion for easy suctioning.
T Philadelphia: F.A.
Davis Company. 8. Monitor oxygen saturation.
E
R: to rule out presence of gas
R
exchange impairement.
N
9. Carry out diagnostic orders made
by the physician such as ABG or AFB
and secure result.
R: to determine the degree of

respiratory impairment such as
presence of hypoxemia.
Date Cues Needs Nursing. Diagnosis Objective Intervention Evaluation
F Objective cues: N Bleeding related to altered Within the 8 1. Monitor patient’s vital February 11, 2010
E clotting mechanism: hours span of signs, especially the @ 10:30 PM
- Melena U
B decreased prothrombin and care, the patient blood pressure
noted Goal Met
R T thrombin production will be able to:
® To obtain baseline
U - Decreas secondary to liver cirrhosis Within the 8 hours
R maintain normal data and prevent
A ed platelet span of care, the
® One of the functions of hemodynamic hypotension
R count of 115 I patient was able to
liver is the production of status as
Y x103 /uL 2. Assess patient’s level of maintain normal
T prothrombin and thrombin evidenced by a
(Normal: consciousness hemodynamic
which are substances normal intake
11, 150-400 I status as
needed to help blood and output ® A change in the level
2010 x103 /uL) evidenced by a
O coagulate. In patients with of consciousness
@ normal intake and
- Gastric liver cirrhosis, they are at indicates a decrease in
5:00 PM N output
lavage higher instances of circulating blood volume
ordered A bleeding because of the
3. Monitor intake and
decreased coagulation
L output
factors.
- ® To determine fluid
balance and prevent
M
dehydration
E
4. Regulate intravenous
T fluids appropriately
A ® To prevent
dehydration and correct
B
the normal
O hemodynamic status
L 5. Monitor hematocrit and

Date Cues Needs Nursing Diagnosis Objective/Goal Intervention Evaluation
/Time
February Objective Cue: N Hyperthermia related to the Within my 1-3 hour 1. Monitor patient’s vital February 11,
11, 2010 U release of endogenous span of care, my signs. 2010
5:00pm - Increased T pyrogen secondary to patient’s body ® serves as baseline data
body R presence of CAP and liver temperature will @
temperature of I cirrhosis decrease from 38.1°C 2. Note chronological and
38.3 T to 36.5-37.5°C. developmental age of client. 8:00pm
I R: Hyperthermia is the ® Elderly or impaired
- Skin O elevation of body temperature individuals ay not be able to GOAL MET
is warm to N above normal range. Most recognize and/or act on
touch A often, it results from infection symptoms of hyperthermia Patient’s body
L somewhere i the body, but it temperature
- Increa may be caused by other 3. Provide tepid sponge decreased
sed - conditions (cancer, allergic bath from 38.1 ° C
respiratory reactions, and CNS injuries). ® promotes heat loss by to 36.7° C
rate of 24 M Macrophages, white blood evaporation and conduction
E cells, and injured cells release
- diagnos T chemical substances called 4. Limit clothing in
is of CAP A pyrogens that act directly on lightweight, loose-fitting
B the hypothalamus, causing its clothes.
O thermostat to be set to a ® encourages heat loss by
- ascites L higher temperature. radiation and conduction.
I
C Reference: 5. Cool the environment
Nurse’s Pocket Guide 10th with air-conditioning or fans.
P Edition by Doenges, et al. ® promotes heat loss by
A convection
T
T 6. Keep clothing and linens
E dry.
R ® to reduce shivering
N
7. Administer replacement
fluids and electrolytes
® to replace fluids lost through
perspiration and respiration.
8. Maintain bedrest
® to reduce metabolic
demands
9. Discuss importance of
adequate fluid intake
® To prevent dehydration
INTERDEPENDENT
10. Collaborate with

dietician in providing patient
with high-calorie diet, or
parenteral nutrition
® to meet increased metabolic
demands
11. Notify physician if

pharmacologic regimen is
inadequate to meet
hyperthermia control goal.
® to determine if there is a
need to increase dosage,
change medication or use a
stepped program (e.g.,
switching from injection to oral
route, or lengthening time
interval between doses).
DEPENDENT
12. Administer antipyretics,

orally or rectally, as ordered.
® to aid in reducing the body
temperature
13. Provide supplemental

oxygen as ordered.
® to offset increased oxygen
demands and consumption.
14. Administer replacement

IV fluids and electrolytes as
ordered.
® to support circulating
volume and tissue perfusion
and to aid in hydration
DATE/ NEE NURSING OBJECTIVES OF
CUES NURSING INTERVENTIONS EVALUATION
TIME D DIAGNOSIS CARE
F Objective: Fluid Within 8 hours span

Volume of care, the client
E N February 11, 2010
Excess in the will be able to : 1. Measure vital signs
B - ascites U interstitial @
® To obtain baseline date and
space related
R -dry, scaly T 11:00 pm
to liver organ a. Stabilize to note any unusualities
and shiny
U R failure as fluid volume as
Goal Unmet
-edema evidenced by evidenced by 2. Assess for evidence of
A I
ascites balanced I/O, dependent venous pooling or Patient was unable to:
R T Vital signs
®In patients venostasis.
-dyspnea within normal o stabilize fluid volume as
Y I with liver
limits
failure, there ® To determine causative evidenced by imbalance
O
is a decreased factors intake and output
1 N production of
albumin. 3. Provide quiet
1 A
Thus, environment, limiting external
, L resulting to
stimuli.
decrease in
-
osmotic
® To promote adequate rest
2 M pressure in
the and comfort for faster
0 E
intravascular recovery
1 T spaces. This
leads to the 4. Monitor intake and output
0 A
accumulation
@ B of fluid in the ® To determine elimination o
Date / Cues Needs Nursing Diagnosis Objective of Nursing Intervention Evaluation
Time Care
w/ Rationale w/ Rationale
February Objective: N Risk for impaired Within my 1. Monitor patient’s vital signs. February 11,
11, 2010 at skin integrity related seven hours 2010; 10pm
- Jaundice U ® serves as baseline data
to prolonged bed rest span of care,
4pm noted in
T the patient 2.) Assess for any changes in skin.
the skin R: When edema and
will maintain Goal Met:
upon R jaundice are present, ® to be able to determine the
undamaged
inspection the skin is placed at causative factors After seven
I physical
. more risk of being hours span of
3.) Note and record degree of jaundice
- +4 pitting T impaired because of Skin integrity care, the patient
of skin and sclera and scratches on the
edema the bilirubin present by not still maintained
I body.
noted on on the blood. manifesting intact skin
all four O signs of ® to be able to assess skin integrity integrity as
Moreover, prolonged
extremitie decubitus evidenced by
N bed rest can form 4.) Maintain strict skin hygiene.
s ulcer. absence of
decubitus ulcers at the
- (+) body A ® to prevent the spread of bacteria decubitus ulcer
patient’s back.
malaise and prevent infection at the patient’s
L
Vital Signs: back.
5.) Provide adequate clothing/covers.
BP- 110/70 Reference :
®to prevent vasoconstriction
mmHg M Nurse’s Pocket Guide 6.) Observe for reddened/blanched
11th Edition by areas and institute treatment
PR- 96 bpm E
Doenges, et al. immediately.
RR- 24 cycles T
®: Reduces likelihood of progression
per minute
A to skin breakdown.
TEMP. – 38.3
B 7.) Change patient’s position every
°C
two hours.
O
®: To relieve the pressure on the
L
patient’s back.
I
8.) Drain urine bag every two hours.
C
To monitor output of patient in order
to determine fluid and electrolyte
intake and loses
P
9.) Encourage frequent skin care to
A
significant other. Also, perform
T morning care to patient by performing
complete bed bath and apply lotion
T
afterwards.
E
®: To promote hygiene and skin
R integrity. To promote skin moisture,
and prevent roughness on skin.
N
10.) Emphasize importance of
adequate nutritional/fluid intake to
significant others. (through NGT
feeding)
®: to maintain general good health

and skin turgor.
11.) Administer medications as

ordered.
® to treat any underlying cause

POST-MORTEM
 Ask permission to the family before doing the post-mortem care.
R: The family is in grieving stage and so nurses should be sensitive enough in dong
responsibilities
 Ask permission to the patient before removing tubing from his body
R: It is to convey respect and value to the patient’s body
 Use caution when removing tape from the body to avoid skin breakdown.
R: The body temperature decreases with a resultant lack of skin elasticity
 Elevate the head to prevent discoloration from the pooling of blood.
R: a physiological change will happen in which a bluish purple discoloration that is a
by-product of red blood cell destruction occurs in the dependent areas in the body.
 The nurse should close the eyelids, insert dentures, close the mouth and position
the body in a natural position as soon as possible after death.
R: To prevent the body from stiffening caused by contraction of skeletal and smooth
muscles.
 Prepare the body: remove all tubes and position the body
R: To make the body look comfortable and natural for family viewing.
 Place the body in a plastic or fabric shroud and put a tag on it.
R: To prepare the body for transport to the morgue.
 Return the deceased’s possession to the family such as jewelries, eyeglasses,
clothing and all personal items.
 Offer to contact support people
 Help the family with decision making regarding funeral home, transportation, and
the removal of the deceased’s belongings.
R: The family needs help since they are on the process of grieving.
 Demonstrate compassion in providing information and support to families.
R: This will inform the family of your genuine concern for them
PROGNOSIS
Criteria Poor Fair Good Justification
Onset of Illness  We rated it poor since the
patient started manifesting
symptoms that are
associated with liver
cirrhosis since December
2009. On January 23, 2010,
13 days prior to his
admission, the patient
experienced headache, chest
pain, dull abdominal pain,
felt nauseated and dizzy..
Duration of  Occurrence of
Illness manifestations related to
liver cirrhosis has been
observed to start since
December 2009. It is also
poor since liver cirrhosis is a
chronic disease. Hospital
days until our last contact
with the patient are 6 days.
Attitude and  As verbalized by his wife,

willingness to the patient is taking
take medications but sometimes
medications with skipped doses because
he neglects to take and due
to forgetfulness.
Age  The patient is 73 years old
and we rated it as poor since
geriatric patients have
deteriorating body systems
that hinder recovery. The
wear and tear theory
suggests that as a person
ages, he or she is more
prone to illness and
resistance and the ability to
heal is getting weaker.
Precipitating  We rated it poor since his
and age and race predisposes
predisposing him in developing the
factors disease. Moreover, his
chronic alcoholism
precipitates the development
of the disease. Longtime
alcohol beverage drinking is

the most common factor that
triggers liver cirrhosis.
Environment  The ward has poor
ventilation, crowded and
noisy. With this, it is not
favorable for recovery.
Family Support  Family support is fair. They
give time in giving care to
the patient but cannot
provide all the needs
especially the medications
and mechanical ventilator
because of financial
inadequacy.
Basis for Prognosis: Poor = 1 Fair = 2 Good = 3
Range of prognosis:
0-1.50 = poor
1.51-2.0 = fair
2.0-2.5 = good
Result:
POOR: Precipitating and predisposing factors, Age, Duration of Illness, Onset of Illness,
Environment
FAIR: Attitude and willingness to take medications and Family Support
GOOD: None
Computation:
Good: 3 x 0 = 0
Fair: 2 x 2 = 4
Poor: 1 x 5 = 5
Total: 9/7 = 1.28 (POOR PROGNOSIS)

RECOMMENDATION
Every rotation we have is a learning course and practice to develop our skills and
hearts as caregivers. In this rotation, the 3rd group of BSN-3H, cultured a lot of
knowledge in this experience; experience that will serve as our guide and basis for
improvement. In relation with improvement, the group had come up with
recommendations, which we think, would have made the exposure a lot better.
To our client’s family:
One of the most important factors of recovery for a certain illness is the
participation of the patient himself. However, our client has suffered a disease wherein he
has gone seriously affected both physically and emotionally and even his consciousness
and responsiveness have been depleted. The family’s involvement in the treatment of the
patient is very essential and highly needed. The family should know all the basic facts
and information about the patient’s illness because them, more than anybody else are
expected not just to care but also to accept his condition with utmost understanding.
Being aware of the illness itself and its treatment will elicit awareness and would
definitely pave the way to the prevention and alleviation of any ailment that any of the
family members may possibly have. To the family members, the death of a love one is
not the end of every one’s life. His death should serve a lesson and be a step towards
taking good care of one’s body.

To the Student Nurses:
In line with this case study, the group members would like to encourage all
student nurses to get more involved in the promotion of health in our country. We are to
provide health services to the greater population in a way that it is more generalized. We
must impart to those who are in need, our knowledge regarding health and on how they
could maintain a healthy lifestyle. We must apply to them the skills that we have learned
by rendering them a quality- based service. We must also teach the patients as well as the
significant others on the alternative means of promoting health and on how to prevent the
possible occurrence of a disease. Empathy must always be shown not just to the patient
but also to the significant others. Student nurses must also be sensitive to the feelings and
emotions not just of the patient but also to the significant others especially in experiences
of death and finite separation.
To the medical world:
We would like to encourage the medical practitioners or the members of the
health care team that they should have to be more committed or compassionate in their
chosen profession. They must have to cater the health needs of the people of different
kinds without putting levels of discrimination on them. Their job is not that easy but they
must have to be very careful because they are already dealing here with the life of a
person. They must have to extend their hands not only in the physical means but also in a
holistic way of giving or providing care to individuals, families and the population groups
especially in significant others who may have lost love ones.. They are tasked to render
their services in order to achieve the good health condition of the citizens of the country
because the health of the nation lies in the health of the populace.
REFERENCES
BLACKWELL’S DICTIONARY OF NURSING 5TH EDITION, 2004
BROWN, K.S (2003) DEVELOPMENTAL THEORY: UNDERSTANDING THE AGES. RETRIEVED FROM
HTTP://WWW.HAVERFORD.EDU/PSYCH/DDAVIS/P109G ERIKSON.STAGES.HTML. RETRIEVED ON
FEBRUARY 12, 2010.
HANDBOOK OF MEDICAL-SURGICAL NURSING 3RD ED. SPRINGHOUSE: 2006
LEIGHTON, S.S., ET AL.(1997) PERSPECTIVE IN HUMAN DEVELOPMENT. RETRIEVED FROM

HTTP://WWW.SLIDESHARE.NET/SUNNYCUTS/JEAN-PIAGETS-THEORIES-OF-DEVELOPMENT. RETRIEVED
ON FEBRUARY 20, 2010.
LINDON, P.S & REESE, R.R. ( 1999) PSYCHOLOGY: APPROACH AND UNDERSTANDING. RETRIEVED
FROM HTTP://PSYCHOLOGY.ABOUT.COM/OD/THEORIESOFPERSONA LITY /A/PSYCHOSOCIAL_3 .HTM.
RETRIEVED ON FEBRUARY 12, 2010.
LINDON, P.S & REESE, R.R. ( 1999) PSYCHOLOGY: APPROACH AND UNDERSTANDING. RETRIEVED
FROM HTTP://EDUCATION.STATEUNIVERSITY.COM/PAGES/2032/HAVIGHURST-ROBERT-J-1900-
1991.HTML. RETRIEVED ON FEBRUARY 12, 2010.

LUCKMANN, K.L & SORENSEN, W.A (2003) : MEDICAL-SURGICAL NURSING: A
PSYCHOPHYSIOLOGIC APPROACH. LOUIS, MISSOURI: MOSBY.
MCTIMOTHY, A.S (2005) PATHOPHYSIOLOGY: A 2-IN-1 REFERENCE FOR NURSES. PHILADELPHIA:

LIPPINCOTT WILLIAMS & WILKINS.
PETERSON, M.L, LUIS, B.D. & CHONG, P.C.(2000)PERSONALITY DEVELOPMENT. RETRIEVED FROM
HTTP://BAMA.UA.EDU/~JSTALLWO/YAL/ARTICLES/YOUNG%20ADULT%20LITERATURE%20IN
%2 0THE%20CLASSROOM.PDF. RETRIEVED ON FEBRUARY 22, 2010.
REYBURN, S. W. (2001) MANUAL OF MEDICAL EDUCATION. RETRIEVEDFROM HTTP://WWW
.AAFP.ORG/AFP /2006/0201/P44 2.HTML ACCESSED ON FEBRUARY 21, 2010
SUDDARTH, D.R. (1991) THE LIPPINCOTT MANUAL OF NURSING PRACTICE, 5TH ED. PHILADELPHIA:
LIPPINCOTT WILLIAMS & WILKINS.
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HTTP://WWW.EMEDICINEHEALTH.COM/CIRRHOSIS/PAGE2_EM.HTM#CIRRHOSIS%20CAUSES.
RETRIEVED ON FEBRUARY 22, 2010.

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ACKNOWLEDGEMENT

strength, and encouragement in making this case presentation possible.

Him, none of these things would be possible.

support, emotionally, spiritually and financially.

keep the spirit of caring burning.

in making the case presentation successful.

take place or by the cause of the disorder.

leading cause of death here in Davao.

it for the future.

To have a course of direction, organization and to recognize the essence of this

study, we have set the following objectives:

MED-CP Ward, we aim:

• To provide an extensive study about Community acquired pneumonia ascites

and be equipped with competence in dealing with related situations in the

• To improve our skills in doing relevant interventions which promote wellness to

persons having the disease;

confronted with the disease but also to empathize with them.

from the past and present illnesses;

Jean Piaget’s Theory;

 Perform cephalocaudal assessment to the client thoroughly;

anatomy and physiology;

indication, result, and their implications; Exudates

Age- elderly adults

Time of admission: 04:09PM Nursing Resp:

Vital signs upon admission: May rupture

Source: Significant others and patient's chart Vitamin E

MALE Nursing Resp:

FEMALE Nursing Resp:

History of past illness

it was just a “Panuhot and Kabuhi”.

Atong mga last week sa January ra pud nako nabantayan”.

Erik Erikson’s Psychosocial Theory of Development

Psychosocial Theory of (65 years old and above) achieved integrity.

development, believed that This stage focuses on According to his wife,

personality develops in a reflecting back on life. Cutie is already contented

sequence of developmental world. No regrets or dong, miskan ana ra na

stages or levels of recriminations. Despair akong bana, wala gyud na

achievement. He described and/or 'Disgust' represent the siya nagmahay ug taman-

eight stages of development opposite disposition: feelings taman sa mga

and in each stage signals a of wasted opportunities, nangahitabo sa among

task that must be regrets, wishing to be able to kinabuhi. Simple ra nga

each developmental stage, feelings of bitterness and among mga anak,

of an individual is. proud of their adlaw-adlaw." Despite of

accomplishments will feel a it, the patient was not able

sense of integrity. to send his three children

Successfully completing this in college. Moreover, the

phase means looking back patient has been alcoholic

with few regrets and a for almost 60 years and

general feeling of been smoking since his

satisfaction. These teenage years. These

individuals will attain habits are wasted

wisdom, even when opportunity and Mr. cutie

confronting death. has not attained the

wisdom since he was not

able to decipher that his

vices would affect his

health in the long run.

Theory Stage Result and Justification

every developmental stage, above) achieved this stage since

certain tasks are needed to some tasks are not