Bicol University College of Nursing Legazpi City

A Case Study on

LIVER CIRRHOSIS

Submitted by: CHARMAINE ERICKA Q. DEL ROSARIO BSN IV C Group 3

Submitted to: DANE MALACAD Student Head Nurse

GARRY L. GRAGEDA Clinical Instructor

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, 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 Filipinosin men, it is the second most common, while in women, it is the ninth most common.

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 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 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.

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.

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)

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.

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

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 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 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.

PATHOPHYSIOLOGY

Symptoms of Cirrhosis of the Liver Individuals with cirrhosis may have few or no symptoms and signs of liver disease. Some of the symptoms may be nonspecific, that is, they don't suggest that the liver is their cause. Some of the more common symptoms and signs of cirrhosis include:

Yellowing of the skin (jaundice) due to the accumulation of bilirubin in the blood Fatigue Weakness Loss of appetite Itching Easy bruising from decreased production of blood clotting factors by the diseased liver.

Individuals with cirrhosis also develop symptoms and signs from the complications of cirrhosis.

MEDICAL MANAGEMENT Medications are used to treat the complications and effects of cirrhosis; they do not reverse or slow the process of cirrhosis itself. Known hepatotoxic drugs and alcohol are avoided, as are drugs metabolized by the liver (e.g. barbiturates, sedatives, hypnotics, and acetaminophen). Diuretics reduce fluid retention and ascites. Spironolactone is frequently the drug of choice because it addresses one of the causes of ascites- increased aldosterone levels. Medications to reduce the nitrogenous load and lower serum ammonia levels are added when manifestations of hepatic encephalopathy develop. The commonly administered medications are lactulose and neomycin. The beta-blocker nadolol (Corgard) may be given together with isosorbide mononitrate to prevent rebleeding of esophageal varices. This drug combination also lowers hepatic venous pressure. Ferrous sulfate and folic acid are given as indicated to treat anemia. Vitamin K may be ordered to reduce the risk of bleeding. When bleeding is acute, packed RBCs, fresh frozen plasma, or platelets may be administered to restore blood components and promote hemostasis. Antacids are prescribed as indicated. Oxazepam (Serax), a benzodiazepine antianxiety/ sedative drug, is not metabolized by the liver, and may be used to treat acute agitation. Generally, liver damage from cirrhosis cannot be reversed, but treatment could stop or delay further progression and reduce complications. A healthy diet is encouraged, as cirrhosis may be an energy-consuming process. Close follow-up is often necessary. Antibiotics will be prescribed for infections, and various medications can help with itching. Laxatives, such as lactulose, decrease risk of constipation; their role in preventing encephalopathy is limited. Alcoholic cirrhosis caused by alcohol abuse is treated by abstaining from alcohol. Treatment for hepatitis-related cirrhosis involves medications used to treat the different types of hepatitis, such as interferon for viral hepatitis and corticosteroids for autoimmune hepatitis. Cirrhosis caused by Wilson's disease, in which copper builds up in organs, is treated with chelation therapy (e.g. penicillamine) to remove the copper.

DRUG STUDY Generic Name

Furosemide Brand Name Classification Furoside, Lasix Myrosemide, Uritol, Diumide-K (functional) Loop diuretic (chemical) Sulfonamide derivative Dosage and Route 40 mg tab OD Mechanism of Action Indication Inhibits reabsorption of sodium and chloride at proximal and distal tubule and in the loop of Henle 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 Effects CNS: headache, fatigue, weakness, vertigo 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 Responsibilities >assess for drowsiness and restlessness for it may indicate metabolic 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 Brand Name Photo

Omeprazole Losec and Prilosec

Classification

Gastric acid secretion, proton-pump inhibitor

Dosage and Route 40mg IVTTq12 Mechanism of Action Indication Suppress gastric acid secretion by inhibiting the partial cell H+/K+ ATP pump 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 Effects CNS: headache, dizziness Neuromascular & Skeletal: weakness, back pain GI: nausea, diarrhea, vomiting, abdominal pain, constipation, taste perversion Respiratory: upper respiratory infection, cough

Nursing Responsibilities

Ensure ten rights of medication administration 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 Brand Name Photo Classification

Spironolactone Aldactone

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 Action

One of the main functions of the kidneys is to retain salt (sodium 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 other agents that can raise blood potassium levels, such as potassium supplements, angiotensin converting enzyme (ACE) inhibitors [for example, enalapril (Vasotec)], indomethacin (Indocin), or other potassium-sparing diuretics. Spironolactone can cause elevation of blood digoxin (Lanoxin) to toxic levels, requiring adjustment of the digoxin dosage. Side/Adverse Effects Lethargy, mental confusion, fatigue, N/V, abd cramps, fluid and electrolyte imbalance

Nursing Responsibilities

IMPLICATIONS: Check blood pressure before initiation of therapy Monitor serum electrolytes Assess for signs for fluid electrolyte imbalance

Monitor daily I&O, check for edema Weigh pt under standard conditions, and daily once therapy commences

Observe for and report immediately the onset of mental changes

TEACHING: Max diuretic effect may not occur until third day of therapy, diuresis may continue 2-3 days after d/c Avoid replacing fluid losses with large amounts of free water Weigh 2 3 times weekly Avoid intake of high potassium foods and salt substitutes

Generic Name Photo

Ceftriaxone

Brand Name Classification Dosage and Route Mechanism of Action

Rocephin cephalosporin antibiotic 1gm IVTTq12 This antimicrobial agent inhibits 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.

Indication Contraindication Drug Interaction

Respiratory tract and intraabdominal infections Cephalosporin hypersensitivity. 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 more closely and adjust your dosage accordingly.

Sulfinpyrazone (Anturane) If you are taking both ceftriaxone and sulfinpyrazone, 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 more closely and adjust your dosage accordingly.

Calcium or Calcium-Containing Products Calcium and calcium-containing products can bind to

ceftriaxone and cause dangerous deposits in the lungs and kidneys. This is most likely to occur in newborns. Therefore, ceftriaxone should never be given to newborns who must also receive a calcium-containing IV product (even if the medications are given at different times).

For any other age group, such calcium IV products can be given, as long as they are not mixed with ceftriaxone or given at the same time. The IV must be thoroughly flushed between ceftriaxone and calcium products. It is important to be aware that many different IV medications contain calcium. Side/Adverse Effects Most people tolerate ceftriaxone well. When ceftriaxone side effects do occur, they are mostly minor and require little or no treatment by a healthcare provider. Common side effects of ceftriaxone include diarrhea; an increase in liver enzymes; and pain, warmth, and/or minor swelling at the injection site. Serious side effects include blood in stools, unexplained bleeding or bruising, and difficulty breathing or swallowing. Nursing Responsibilities 1. Ensure the ten rights of medication administration 2. Assess patients history of allergy to cephalosporins and penicillin, if there is any hypersensitivity 3. Check vital signs to naote any changes after giving the

medication. 4. Observe signs and symptoms of anaphylaxis (rash, pruritus, laryngeal edema, wheezing). Discontinue medication and notify physician or other healthcare professional immediately if these symptoms occur. 5. Inform patient to use only ceftriaxone only for bacterial infections, not for viral infections such as the common cold 6. Check signs for diarrhea. Diarrhea may be a sign of infection. Note for watery or bloody stools. 7. Note for new signs of infections such as the occurrence of persistent sore throat and fever. 8. Advise patient to report signs of superinfection (furry overgrowth on the tongue, vaginal itching or discharge, loose or foul-smelling stools) and allergy. 9. If the patient is breastfeeding, inform not to take the medication without consulting the doctor since ceftriaxone may pass into breast milk and could harm a nursing baby. 10. Avoid taking the medications with anticoagulants to prevent bleeding. 11. Stop administration of drugs if unusualities occur. 12. Store drug at room temperature away from moisture and heat.

Generic Name Photo

metronidazole

Brand Name Classification Dosage and Route Mechanism of Action

Flagyl Anti-infectives, antiprotozoals, antiulcer agents 500mg 1 TAB q6 Disrupts DNA and protein synthesis susceptible organisms. 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. EENT: Tearing (topical only). GI: Abdominal pain, anorexia, nausea, diarrhea, dry mouth, furry tongue, glossitis, unpleasant taste and vomiting. Hemat: Leukopenia Neuro: Peripheral neuropathy Nursing Responsibilities - Administer on empty stomach or may administer with food or milk to minimize GI irritation. - Instruct patient to take medication exactly as directed with evenly spaced times between doses, even if feeling better. - Advised patient to not skip doses or double up on missed doses.

- Inform patient that medication can cause metallic taste. - Advise patient that frequent mouth rinses, good oral hygiene and sugarless gum or candy may minimize dry mouth. - Inform patient that medication may cause urine to turn dark. - Advise patient to consult health care professional if no improvement in a few days or if signs and symptoms of superinfection (black furry overgrowth on tongue or foulsmelling stools) develop

SURGICAL MANAGEMENT Transplantation If complications cannot be controlled or when the liver ceases functioning, liver transplantation is necessary. Survival from liver transplantation has been improving over the 1990s, and the five-year survival rate is now around 80%, depending largely on the severity of disease and other medical problems in the recipient. In the United States, the MELD score (online calculator) is used to prioritize patients for transplantation. Transplantation necessitates the use of immune suppressants (cyclosporine or tacrolimus).

DISCHARGE PLAN MEDICATION Describe the importance of regularly taking of prescribed medications including the potential unpleasant effects of non compliance Instruct the client to continue with follow up medical care Advise the client not to miss the intake of medications given by her physician upon discharge.

ENVIRONMENTAL CONCERNS Instructed patient to provide a peaceful relaxing, comfortable and well ventilated room. Instructed patient to provide a stress free environment. Instructed patient to follow the prescribed meal plan. Instructed to provide clean environment to prevent lodging of infectious microorganisms.

TREATMENTS Discussed on the importance of strict adherence to medication regimen to ensure complete healing.

Instructed patient to understand and follow discharge instruction religiously and accurately. Instructed patient to follow proper instruction on medication prescribed by the physician. Teach the patient the dosages, routes, and side effects for all medications. Review drug and food interactions with the patient.

HEALTH TEACHINGS Instruct patient to limit his activity for 24 to 48 hrs after discharge. Review information about medications to be taken at home, including name, dosage, frequency and possible side effects, discussed the importance of continuing to take. Patient is counseled regarding importance of eating meals on time and in a relaxed setting. Instructed patient to avoid any strenuous or heavy activities. Teach postoperative care to patients who have had surgery. Teach the patient how to plan a paced progression of activities. Instruct the patient to report bowel elimination problems to the physician. Emphasize that, in the case of recurrent abdominal pain, fever, or vomiting, the patient should go to the emergency department for evaluation. Teach patient the care for the surgical site; notify the physician if any signs of poor wound healing, bleeding, or infection are observed.

OUT PATIENT (FOLLOW UP CHECK-UP) DIET Eating fewer residues may help improve your pain, abdominal cramping or fullness and gas. Residue means high fiber foods, stringy foods and foods with skins and seeds. Patient will be advised to go back in the hospital in a specific date to have a follow-up check up after discharge Consult doctor for are any problems or complications encountered.

Advice patient to eat high fiber foods like Vegetables, Whole grains, Nuts and seeds, Beans and legumes, Fresh and dried fruits. Eat only as much as you feel comfortable and do not force food! Chew all solid foods well. Eat small meals large meals may lead to more discomfort and/or cramping. Aim for 5 or 6 small meals rather than 3 large meals. Drink as much as you can. Try to have 6 to 8 cups of fluids each day. You may need to take a multivitamin if you cannot eat as much as usual or if your diet is severely restricted. Discuss this with your doctor or dietitian.

SPIRITUAL Nursing actions to help clients meet their spiritual needs include: Providing presence Supporting religious practices Assisting clients with prayer Referring client for spiritual counseling