SYSTEMS PLUS COLLEGE FOUNDATION

MacArthur Highway, Balibago, Angeles City

COLLEGE OF NURSING

CASE STUDY

in

MATERNITY WARD

(Institution/ Area)

In partial Fulfillment of the Requirements

In the Nursing Care Management 109 – RLE

Submitted by:

GROUP 4 - NURO4B

Castro, Maruella

Dayrit, Gil Matthew B.

Escobar, Myrna

Ganaban, Andrew

Gomez, Kadelyn

Oliver, Verheugen

Submitted to:

Prof, Jerald Mendoza, RN

Clinical Instructor, NCM 109 -RLE

May 14, 2024

Date
 Case Scenario:

An Eight-year-old pediatric patient named Nunez, John Patrick Canlas was admitted to the

pediatric unit in Jose B. Lingad Memorial General Hospital with a history of chronic liver disease,

likely secondary to autoimmune hepatitis type 1 or Wilson disease, presenting with massive

ascites and hypoalbuminemia. The admitting diagnosis indicates the complexity of his condition,

which requires close monitoring and specialized care. Upon admission, John underwent a series

of tests, including hematological, biochemical assessments, and chemistry test to better

understand the extent of his liver disease and its impact on her overall health.

I. INTRODUCTION

Brief description of the diseases:

Autoimmune hepatitis type 1 is a chronic inflammatory liver disease characterized by

the body's immune system mistakenly attacking liver cells, leading to inflammation and

damage. Wilson disease, on the other hand, is a genetic disorder that causes copper to

accumulate in various organs, particularly the liver and brain, resulting in liver damage and

neurological symptoms. The presence of massive ascites, the accumulation of fluid in the

abdominal cavity, suggests advanced liver disease and portal hypertension, a common

complication of chronic liver conditions. Hypoalbuminemia, indicated by low levels of serum

albumin, highlights malnutrition and impaired liver function, as albumin is produced by the liver

and plays a crucial role in maintaining fluid balance in the body. Further diagnostic tests,

including hematological, biochemical, and chemistry assessments, were conducted to evaluate

the extent of John's liver disease and its impact on his overall health. These tests provide

valuable information about coagulation function, blood cell counts, and liver enzyme levels,

aiding in the management and treatment of his condition.

Current trends about the disease condition:

Medical advancements have led to more precise diagnostic tools for chronic liver

diseases like autoimmune hepatitis type 1 or Wilson disease. Techniques such as genetic

testing, imaging modalities like MRI or CT scans, and advanced biochemical assays help in

accurate diagnosis and understanding disease progression. Moreover, tailoring treatment

 plans based on individual patient characteristics and disease severity is a growing trend. With

advancements in pharmacogenomics and precision medicine, healthcare providers can select

therapies that are most effective and least toxic for pediatric patients like John, taking into

account factors such as age, weight, genetic predisposition, and comorbidities. Furthermore,

an ongoing research effort focus on understanding the underlying mechanisms of chronic liver

diseases in pediatric patients and developing novel therapeutic interventions. Clinical trials

investigating new drugs, immunomodulatory therapies, and gene therapies offer hope for

improved outcomes and quality of life for children like John with complex liver conditions.

These current trends about this condition reflect the developing field of pediatric hepatology

and highlight the importance of comprehensive, patient-centered care in managing chronic

liver diseases in children.

Reasons for choosing such case presentation:

The reason for selecting John's case involves different reasons of complication due to

his chronic liver disease, likely secondary to autoimmune hepatitis type 1 or Wilson disease.

This complexity provides an opportunity for healthcare professionals, medical students, and

researchers to further explore into the intricacies of diagnosing, managing, and treating such

challenging cases. Furthermore, by highlighting a pediatric patient like John emphasizes the

unique considerations and challenges in managing liver diseases in children. Pediatric liver

diseases often present differently from adult cases and require specialized care encouraged to

the developmental stage, nutritional needs, and psychosocial aspects of young patients.

Objectives:

1. Nurse-Centered

To provide comprehensive and compassionate care to John Patrick Canlas Nunez, an

eight-year-old pediatric patient admitted with chronic liver disease, ensuring optimal

management of symptoms, monitoring for complications, and supporting his overall well-being

throughout his hospitalization:

 Conduct thorough assessments of John's vital signs, fluid status, nutritional intake,

and pain levels to identify any changes or deterioration in his condition.

  Implement appropriate interventions to alleviate John's symptoms, such as

administering medications for pain relief, addressing discomfort associated with

ascites, and implementing measures to manage hypoalbuminemia-related

complications like edema and fatigue

 Monitor John's fluid intake and output meticulously, taking into account his massive

ascites and risk of fluid overload or dehydration.

 Administer medications prescribed for John's liver disease management, such as

immunosuppressants or chelating agents, ensuring accurate dosing, timing, and

monitoring for adverse effects.

 Recognize and address John's emotional needs and psychological well-being,

offering age-appropriate explanations, reassurance, and distraction techniques to

alleviate anxiety or fear related to his condition and hospitalization.

2. Client-Centered

 Provide age-appropriate explanations to John or to his parents/significant other

about his liver disease, including its causes, symptoms, and treatment options, using

language and materials that he or his significant other can comprehend.

 Teach John’s parents/significant other or John age-appropriate self-care skills and

strategies to manage his condition, such as adhering to medication schedules,

monitoring symptoms, and recognizing signs of potential complications.

 Provide a supportive and empathetic environment for John to express his feelings,

fears, and worries about his health and hospitalization.

 Involve John's family as partners in his care, providing support, guidance, and

resources to help them navigate the challenges of managing his chronic liver

disease. Offer opportunities for family members to participate in decision-making

processes, learn about John's condition, and acquire skills to support his ongoing

care and recovery at home.

 Develop a comprehensive discharge plan in collaboration with John, his family, and

the healthcare team, ensuring seamless transitions between the hospital and home

settings.
II. NURSING ASSESSMENT

NAME: NUNEZ, JOHN PATRICK CANLAS

AGE: 8 YEARS OLD

SEX: MALE

RELIGION: ROMAN CATHOLIC

NAME OF MOTHER: CANLAS, JULIE ANN

NAME OF FATHER: UNKNOWN

ADDRESS: 1077 SAN FRANCISCO ST. SANTA TERESITA

DATE OF BIRTH: MAY 23, 2015

PLACE OF BIRTH: Angeles City, Pampanga

NATIONALITY: FILIPINO

DATE OF ADMISSION: APRIL 29, 2024

FAMILY HISTORY

- John’s Chronic Liver Disease Secondary to Autoimmune Hepatitis Type 1 and

Wilson Disease massive ascites secondary to consider Hypoalbuminemia was inherited to

his father

HISTORY OF PAST ILLNESS

- Unknown

HISTORY OF PRESENT ILLNESS

- Chronic Liver Disease Secondary to Autoimmune Hepatitis Type 1 and Wilson

Disease massive ascites secondary to consider Hypoalbuminemia

PHYSICAL EXAMINATION
- Blood Pressure: 100/50 mmHg

- Heart Rate: 89 bpm

- Respiratory Rate: 26 breaths per minute

- Temp: 36.5 °C

CLINICAL FINDINGS:

Telmatology Test Normal Values

 Hemoglobin: 85g/h 115 - 148 g/dl

 LTCT: 0.27 (89) (0.27) 0.38 - 0.44

 RBC: 2.8 (2.9) mcL 3.8 – 5.4 mcL

 WBC: 3.0 (3.9) mm3 4.0 – 11.0 mm3

 Neutrophils: 66.5 (76.2) x10^9/L 45.0 – 55.0 x10^9/L

 Lymphocytes: 21.8 (14.3) x10^9/L 38.0 – 45.0 x10^9/L

 Amniocytes: 6.1 (7.6) x10^9/L 3.0 – 6.0 x10^9/L

 Eosinophils: 3.0 (1.4) x10^9/L 2.0 – 5.0 x10^9/L

 Basophils: 2.6 (0.5) x10^9/L 0.0 – 1.0

 Platelet: 80 (81) 3x10^11/unit 250 – 510 3x10^11/unit

 MCV: 97.3 (91.8) fl 80.0 – 100.0 fl

 MCHC: 316 (335) g/dl 310 – 370 g/dl

 RDW – W: 0.228 (0.81) fl 0.110 – 0.160 fl

 RDW – SD: 74.9 (67.8) fl 35.0 – 56.0 fl

 MPW: 10.3 (11.5) n/mm2 6.5 – 12.0 n/mm2

Chemistry Test

April 29, 2024

 Protein: 63.10 g/L 66.87 g/L

  Albumin: 16.90 g/L 35 – 52 g/dl

 Globulin 46.20 g/L 29 -31 g/L

 A/G Ratio: 3.66 g/dl 12 – 17 g/dl

 SGOT / AST: 82.30 IV/L 0.40 IV/L

 Sodium: 129.00 mmol/L 136 – 145 mmol/L

 Potassium 2.40 mEq/L 3.5 – 5.1 mEq/L

 Ionized calcium: 1.08 mg/dL 1.12 – 1.33 md/Dl

 ABOTYPING A

 PH TYPING POSITIVE (+)

May 1, 2024

 Sodium: 133.00 mmol/L 136 – 145 mmol/L

 Potassium: 2.90 mEq/L 3.5 – 5.1 mEq/L

 Ionized Calcium: 1.10 mg/dL 1.12 – 1.33 mg/dL

May 6, 2024 #4

 Protein: 64.90 g/dL 66 – 87 g/dL

 Albumin: 20.10 g/dL 35 – 52 g/dL

 Globulin: 44.80 g/dL 29 – 31 g/dL

 A/G Ratio: 4.49 g/dL 12 -17 g/dL

May 6, 2024 #5

 Albumin: 20.40 g/dL 35 – 52 g/dL

 Globulin: 45.60 g/dL 29 – 31 g/dL

 A/G Ratio: 4.49 g/dL 12 – 17 g/dL

III. ANATOMY AND PHYSIOLOGY

A. Liver

 Anatomy

The liver is the largest parenchymal organ in the abdominal cavity. It is located below the

diaphragm, extending from the right hypochondrium to the epigastrium, usually reaching the left

subcostal edge. It has a smooth, dome‐shaped diaphragmatic surface and a visceral, more irregular

one, molded by the adjacent organs and indented by the left, right, and interlobar fissures

Figure no.1: Anterior, Lateral, and Posterior of the Liver

The liver is located below the diaphragm, extending from the right hypochondrium to the

epigastrium, usually reaching the left subcostal edge. The liver is shown here from three different

angles: anterior, right lateral and posterior. As explained in the figure, in order to explore the liver

appropriately, different angles of intonation are necessary.

 Figure no. 2: Anatomy and Physiology of the Liver

The liver has a smooth, dome‐shaped diaphragmatic surface and a mildly irregular visceral one,

which is molded by the adjacent organs and indented by the interlobar fissures. In normal conditions,

the liver has smooth margins and regular contour, the echotexture is homogeneous, and the

echogenicity is almost equal to or slightly brighter than the cortex of the right kidney.

 Physiology

It interacts with the endocrine and gastrointestinal systems by aiding in digestion and metabolism.

The liver is the storage location for fat-soluble vitamins and handles cholesterol homeostasis. It stores

iron and copper.

B. Autoimmune Hepatitis Type 1

Autoimmune hepatitis refers to chronic and progressive inflammation of the liver from an unknown

cause. The proposed mechanism for the development of autoimmune hepatitis is thought to be the

interplay of genetic predisposition, an environmental trigger, and failure of the native immune system

resulting in chronic inflammation of hepatocytes and subsequent fibrosis of the liver.

Figure no. 3:

Anatomy and Physiology of Autoimmune Hepatitis

Autoimmune Hepatitis is a complex and chronic liver disease that affects thousands of

individuals worldwide. It is an autoimmune disorder, which means that the body's immune system

mistakenly attacks healthy liver cells, causing inflammation and damage over time. This condition can
occur at any age, but it is more commonly diagnosed in women and those with a family history of

autoimmune diseases.

 Pathophysiology

Figure no. 4: Autoimmune Hepatitis Type 1 Treatment

The current proposition for pathogenesis is thought to be secondary to a failure of immune

tolerance in a genetically susceptible individual leading to a T-cell mediated inflammation caused by

various environmental triggers. Common triggers include infections, medications, and toxins. Certain

human leukocyte antigen (HLA) haplotypes are more susceptible to the development of autoimmune

hepatitis.

C. Wilson

Disease

massive

ascites

secondary

to consider

Hypoalbuminemia
 Figure no. 5: Anatomy of Wilsons Disease
Wilson disease or hepatolenticular degeneration is an autosomal recessive disease which

results in an excess copper build up in the body. It primarily affects the liver and basal ganglia of the

brain, but it can affect other organ systems too. Symptoms usually are related to the brain and liver.

Liver-related symptoms include vomiting, weakness, ascites, swelling of the legs, yellowish skin, and

itchiness. Brain or neurological symptoms include tremors, muscle stiffness, trouble speaking,

personality changes, anxiety, and auditory or visual hallucinations.

Wilson disease is an autosomal recessive condition caused by a mutation in the Wilson

disease protein gene. For a person to be affected, a copy of the gene from each parent needs to be

inherited. Diagnosis is difficult and involves blood tests, urine tests, and a liver biopsy along with the

clinical evaluation. Genetic testing may be used to screen the family members of those affected.

 Pathophysiology
 Figure no. 6: Pathogenesis of Wilson’s disease

The genetic defect in Wilson disease impairs copper transport. The impaired transport

decreases copper secretion into the bile, thus causing the copper overload and resultant

accumulation in the liver, which begins at birth. The impaired transport also interferes with

incorporation of copper into the copper protein ceruloplasmin, thus decreasing serum levels of

ceruloplasmin.

IV. PATIENT AND HER ILLNESS

A. Pathophysiology

Figure no. 7: Pathophysiology of Chronic Liver Disease

a. Chronic Liver disease

Chronic liver disease represents a continuous and progressive process of hepatic fibrosis

(scarring of the tissue), liver tissue architectural distortion, and regeneration nodule formation. In

cirrhosis, the liver becomes hard, shrunken, and nodular and displays impaired function and

diminished reserve because of a decreased amount of functioning liver tissue. More importantly, the

physics of blood flow is altered such that the pressure in the portal vein is elevated. As a result, the

blood is diverted around the liver rather than filtered through the liver. This phenomenon, termed

portal-to-systemic (or portosystemic) shunting, has profound effects on the function of various organ

systems and sets the stage for certain devastating complications of liver disease.

Stages of liver disease

  Fibrosis

Refers to the accumulation of tough, fibrous scar tissue in the liver. At the same time, the

process of breaking down or degrading collagen is impaired. Fibrosis occurs when excessive scar

tissue builds up faster than it can be broken down and removed from the liver.

 Cirrhosis

Liver fibrosis can become so extensive that the architecture of the liver is altered — this is

called cirrhosis. As cirrhosis develops, scar tissue replaces healthy liver cells. The usual smooth

texture of the liver becomes nodular causing the free flow of blood throughout it to be compromised,

thus reducing the ability of the liver to perform its many functions.

Causes of liver disease

 Alcohol Liver Disease

 Non-alcoholic Fatty Liver Disease (NAFLD/NASH)

 Chronic Viral Hepatitis

 Genetic Causes

 Alpha-1 antitrypsin deficiency: most common genetic cause of CLD among children.

 Hereditary hemochromatosis: It is an autosomal recessive disorder of iron absorption.

 Wilson disease: Autosomal recessive disorder leading to copper accumulation.

 Autoimmune Causes

 Primary biliary cirrhosis (PBC): An autoimmune and progressive disease of the liver.

 Primary Sclerosing Cholangitis (PSC): commonly associated with ulcerative colitis.

 Autoimmune hepatitis (AIH): This is a form of chronic inflammatory hepatitis.

 Figure no. 8: AIH type 1 Pathogenesis

b. Autoimmune Hepatitis type 1

Autoimmune Hepatitis is characterized by immune-mediated hepatocyte injury associated with

the destruction of liver cells, causing inflammation, liver failure, and fibrosis. Autoimmune hepatitis is

a chronic liver disease that begins with a mistake of the immune system. The immune system sends

antibodies to liver tissues, causing inflammation (hepatitis). These antibodies are normally supposed

to attack infections in liver tissues. But in autoimmune disease, your immune system mistakenly

attacks your own healthy cells instead.

Autoimmune hepatitis causes chronic inflammation in the liver, which may cause serious

damage over time. Like other types of chronic hepatitis, autoimmune hepatitis can lead to scarring of

your liver tissues (cirrhosis). Medical treatment can help reduce inflammation and prevent

complications from developing. Autoimmune Hepatitis type 1 is distinguished by the presence of anti-

smooth muscle antibodies (ASMA) with or without anti-nuclear antibodies (ANA).

Figure no. 9: Wilson Disease Pathogenesis

c. Wilson Disease
 The genetic defect in Wilson disease impairs

copper transport. The impaired transport decreases

copper secretion into the bile, thus causing the copper

overload and resultant accumulation in the liver,

which begins at birth. The impaired transport also

interferes with incorporation of copper into

the copper protein ceruloplasmin, thus

decreasing serum levels of ceruloplasmin.

Hepatic fibrosis develops, ultimately causing cirrhosis. Copper diffuses out of the liver into the

blood, then into other tissues. It is most destructive to the brain but also damages the kidneys and

reproductive organs and causes hemolytic anemia. Some copper is deposited around the rim of the

cornea and edge of the iris, causing Kayser-Fleischer rings. The rings appear to encircle the iris.

Figure no. 10: Ascites

d. Ascites

The first abnormality that develops is portal hypertension in the case of cirrhosis. Portal

pressure increases above a critical threshold and circulating nitric oxide levels increase, leading to

vasodilatation. As the state of vasodilatation becomes worse, the plasma levels of vasoconstrictor

sodium-retentive hormones elevate, renal function declines, and ascitic fluid forms, resulting in

hepatic decompensation.

Through the production of proteinous fluid by tumor cells lining the peritoneum, peritoneal

carcinomatosis also can cause ascites. In high-output or low-output heart failure or nephrotic

syndrome, effective arterial blood volume is decreased, and the vasopressin, renin-aldosterone, and
sympathetic nervous systems are activated, leading to renal vasoconstriction and sodium and water

retention.

Figure no. 11: Hypoalbuminemia

e. Hypoalbuminemia

One of the definitions of CKD includes the presence of significant albuminuria 30 to 300 mg

per 24 hours over at least a period of 3 months. This can occur in the presence or absence of a

decreased glomerular filtration rate (GFR). End-stage renal disease (ESRD) is associated with

significant proteinuria and albuminuria together with serum hypoalbuminemia. The hypoalbuminemia

in ESRD is also a result of the decreased synthesis and increased degradation of protein in this

condition.

B. Definition of the Disease

a. Chronic Liver disease

Chronic liver disease (CLD) is a progressive deterioration of liver functions for more than six

months, which includes synthesis of clotting factors, other proteins, detoxification of harmful products

of metabolism, and excretion of bile. CLD is a continuous process of inflammation, destruction, and

regeneration of liver parenchyma, which leads to fibrosis and cirrhosis. The spectrum of etiologies is

broad for chronic liver disease, which includes toxins, alcohol abuse for a prolonged time, infection,

autoimmune diseases, genetic and metabolic disorders. Cirrhosis is a final stage of chronic liver

disease that results in disruption of liver architecture, the formation of widespread nodules, vascular

reorganization, neo-angiogenesis, and deposition of an extracellular matrix.

b. Autoimmune Hepatitis type 1

 Autoimmune hepatitis is a chronic disease in which your body’s immune system attacks the

liver and causes inflammation and liver damage. Without treatment, autoimmune hepatitis may get

worse and lead to complications, such as cirrhosis and liver failure. Autoimmune hepatitis is an

autoimmune disease. Your immune system normally makes large numbers of antibodies and

lymphocytes that help fight off infections. The normal immune system does not attack healthy cells in

a person’s body. In autoimmune diseases, your immune system makes certain types of antibodies—

called autoantibodies—and lymphocytes that attack your body’s own cells and organs. Type 1 AIH,

the “classic” type, is also the most common. Type 1 involves anti-smooth muscle antibodies (ASMA)

that attack the smooth muscle cells in your liver.

c. Wilson Disease

Wilson's disease is a rare inherited condition that causes copper levels to build up in several

organs, especially the liver, brain, and eyes.

d. Ascites

Ascites is the pathologic accumulation of fluid within the peritoneal cavity. It is the most

common complication of cirrhosis.

e. Hypoalbuminemia

Hypoalbuminemia happens when the body doesn’t produce enough of the albumin protein, or

when there is loss of too much albumin in through urine or stool. Liver makes albumin, which

prevents fluid from leaking out of blood vessels into your tissues.

C. Synthesis of the Disease

C.1 Risk Factors (Patient-Based):

● According to Ms. Canlas, mother of the patient, there was no known family health history of

Chronic liver disease on the mother's side. Although Ms. Canlas suspects that the disease

may be contracted or inherited from the father’s side of the family.

● However, the mother mentioned that the patient was born at 32 weeks age of gestation,

which puts the patient into the premature birth spectrum. Weighing the fact that the patient

was born premature, the patient is deemed to be at a greater than normal risk of
 developing certain kinds of diseases or contracting infections due to the immature organs

and immunity that accompanies premature birth.

C. 2 Signs and Symptoms (Patient-Based)

 Through observational assessment and patient's records, the patient manifests chronic liver

disease related signs and symptoms namely, distended abdomen, bipedal edema, itching,

DOB, fatigue, muscle loss, jaundice, and ascites, which are common in chronic liver

disease.
V. MEDICAL MANAGEMENT

A. DIAGNOSTIC AND LABORATORY PROCEDURES

DIAGNOSTIC/ DATE ORDERED

GENERAL INDICATION OR NORMAL ANALYSIS AND NURSING
LABORATORY DATE RESULTS RESULTS
DESCRIPTION PURPOSE VALUES INTERPRETATION RESPONSIBILITIES
PROCEDURES IN

Complete Blood Count (CBC) test is done for individual who diagnose with chronic liver disease to monitor various aspects of their blood health. hemoglobin levels,
detect anemia, assess platelet count, and ensure overall health before further medical procedure.

Hemoglobin Date Ordered: Hemoglobin is a To measure the 85g/L 115 - 148 g/dL Within lower  Verify patient
May 1,2024 protein in red amount of range identification
blood cells that hemoglobin in the  and explain the
(2:00pm)
binds to oxygen blood that has procedure.
Date Results and the capacity to
In:
carries it carry oxygen all  Ensure patient
May 1, 2024 throughout the throughout the comfort during
body, tissues/ body blood sample
(5:30 pm)
facilitating since an collection and
oxygen delivery abnormally low educate the
to tissues and HgB can be an patient that there
organs. indication of will be discomfort
anemia. during the
Hematocrit Date Ordered: Hematocrit is the Measuring 0.27 0.38-0.44 Within lower procedure.
ratio of hematocrit levels % range
 May 1,2024 Red Blood Cells identifies the  With the
(RBC) to the total percentage collaboration of
(2:00pm)
blood of the body volume of RBC in other healthcare
the providers,
Date Results
overall blood of collecting blood
In: the body which samples from the
indicates levels of patient is done.
May 1, 2024
blood- oxygen

(5:30pm) carrying capacity.  Label samples

RBC Count Date Ordered: Red Blood Cell In order to 2.9 3.8 -5.4 Within lower accurately and
May 1, 2024 (RBC) Count monitor and early range send them for

measures the diagnose any analysis promptly.

(2:00pm)
level of RBC in abnormalities in
Date Results the blood which levels which  Monitor for signs

In: delivers oxygen could be an of bleeding or

in the body. indication of hematoma
May 1, 2024
conditions  formation post-
affecting RBC procedure.
(5:30pm)
like anemias.
MCV Date Ordered: Mean To assess the 91.8 80.0 - 100.0 Within normal  Educate patient on
Corpuscular average size of range potential
May 1, 2024
Volume, or red blood cells, discomfort or
(2:00pm) MCV, is a CBC- aiding in the bruising at the
based measure diagnosis of puncture site
 Date Results of the average various types of

In: size of red blood anemia and  Review CBC

cells. ensuring patient  results and report
May 1, 2024 health. abnormalities in
the healthcare
(5:30pm)
teams.
MCH Date Ordered: Mean To detect early 30.8 27.0 - 34.0 Within normal

May 1, 2024 Corpuscular complications like range

Hemoglobin, or deficiency that
(2:00pm) MCH, measures leads to anemia
the average that endanger the
Date Results amount of HgB individual l well-
In: per RBC. being.

May 1, 2024

(5:30pm)
MCHC Date Ordered: Mean To detect early 335 310- 370 Within normal
Corpuscular complications like range
May 1, 2024
Hemoglobin deficiency that
(2:00pm) Concentration, leads to anemia
or MCHC, that endanger the
Date Results measures the individual l well-
In: level of being.
concentration of
 May 1, 2024 HgB in a given
volume of packed
(5:30pm)
RBC.
WBC COUNT Date Ordered: The WBC The WBC 3.9 4.0 -11.0 Within lower

May 1, 2024 count measures A white blood cell range

the number of (WBC) test for a
(2:00pm) white blood cells patient with
in a blood chronic liver
Date Results sample, reflecting disease is
In: the typically done to
body's immune assess the
May 1, 2024 response and immune system's
helping identify response. In liver
(5:30pm)
infections or disease, there's
inflammation. an increased risk
of infections due
to impaired
immune function.
Monitoring WBC
count helps
doctors gauge
the patient's
ability to fight
infections and
 assess the
severity of their
condition.
Neutrophil Neutrophils are a An elevated 76.2 45.0 - 55.0 Within higher
type of white neutrophil count % Range
blood cell that in a patient with
plays a critical chronic liver
role in the body's disease could
immune indicate an
response by inflammatory
combating response, which
bacterial is common in
infections and liver diseases like
clearing cellular hepatitis or
debris. cirrhosis. The
liver plays a
crucial role in
regulating the
immune system,
and when it's
compromised, it
can lead to
various immune
dysfunctions.
 response,
ensuring the
early detection of
infections and
optimal health for
the individual.
Eosinophils Eosinophils are a Eosinophils are a 3.0 2.00 - 5.00 % Within Normal
type of white type of white Range
blood cell blood cell
involved in the involved in the
immune body's immune
response, response,
particularly in particularly
combating against parasites
parasitic and allergic
infections and reactions. In
allergic reactions. chronic liver
disease, elevated
eosinophil levels
might indicate a
parasitic infection
or an allergic
reaction.
Monitoring
 eosinophil levels
can help
healthcare
providers identify
these potential
complications in
patients with liver
disease.
Monocytes Monocytes are a Monocytes play a 2.4 3.00 - 6.00 % Within lower
type of white role in chronic range
blood cell that liver disease by
plays a key role participating in
in immune the inflammatory
defense by response and
engulfing and tissue repair. In
destroying conditions like
pathogens and liver cirrhosis,
foreign they can
substances. contribute to the
development of
fibrosis and
exacerbate
inflammation.
Their main
 purpose is to help
regulate the
immune
response and
assist in tissue
healing, although
in chronic liver
disease, their
function can
become
dysregulated,
contributing to
ongoing liver
damage.
Lymphocytes Lymphocytes are The lymphocyte 21..8 38.00 - 45.00 Within lower
a type of white test in pregnancy % Range
blood helps assess
cell critical for maternal immune
immune function and
response, detect any
including the abnormalities that
recognition and may impact the
elimination of health of both the
pathogens and mother and the
 abnormal cells. fetus.
Platelet Count Platelet count Platelet count in 81 250 - 510 Within lower
measures the pregnancy is Range
number of crucial for
platelets in the assessing clotting
blood, which are function and
essential for detecting
blood clotting and potential
preventing complications
excessive such as
bleeding. gestational
thrombocytope
nia or
preeclampsia,
ensuring
maternal and
fetal well-being.
Chemistry tests are often conducted for pediatric patients with chronic liver disease to assess liver function, enzyme levels, and the overall health of
the liver. These tests can help monitor the progression of the disease, identify any complications, and guide treatment decisions. Additionally, they
provide valuable information for healthcare providers to manage the patient's condition effectively.
Sodium Date Ordered: Sodium is Sodium tests play 133.00mmol 136-145 Within normal  Establish
May 1,2024 abundant in a vital role in range rapport with
(2:00pm) nature and is managing the the patient.
Date Results ln: essential for care of patients  Verify patient
May 1, 2024 many biological with chronic liver identification.
 (5:30pm) processes, disease by  Explain the
including nerve assessing fluid procedure
function, muscle balance, liver clearly.
contraction, and function,  Assist with
fluid balance. It is prognosis, and specimen
commonly found guiding treatment collection.
in table salt decisions.  Ensure proper
(sodium chloride) labeling and
and various other documentation.
compounds.  Follow safety
Sodium plays a precautions.
crucial role in  Monitor patient
maintaining response.
electrolyte  Provide follow-
balance in the up and
body and is education on
involved in test results.
regulating blood
pressure and pH
levels.
Potassium Date Ordered: Potassium levels Potassium levels 4.49 3.50 - 5.30 Within Normal
May 1, 2024 in chemistry tests are monitored to mmol/L Range
(2:00pm) indicate ensure
Date Results In: electrolyte electrolyte
 balance and are balance, which is
crucial for vital for
monitoring maintaining
cardiac function normal
and overall physiological
health. functions and
preventing
complications
such as
hypertension.
Ionized calcium Date Ordered: Ionized calcium Monitoring 1.10 1.12 - 1.33 Within lower
May 1, 2024 refers to the ionized calcium Range
(2:00pm) portion of calcium levels can
Date Results in the blood that provide insight
In: is freely into various
May 1, 2024 circulating and medical
(5:30pm) biologically conditions,
active. It's including those
important for affecting the
muscle function, bones, kidneys,
nerve and parathyroid
transmission, and glands
other
physiological
processes.
Monitoring
ionized calcium
levels can
provide insight
into various
medical
conditions,
including those
affecting the
bones, kidneys,
and parathyroid
glands.
 B. IVF

TYPE OF MEDICAL DATE STARTED DATE GENERAL INDICATION OR NURSING

CLIENTS RESPONSE
MANAGEMENT CHANGED DESCRIPTION PURPOSE RESPONSIBILITIES

D5NSS 1L DATE STARTED D5NSS 1L typically D5NSS typically stands For clients with chronic  Verify physician's
05/06/24 refers to a liter of for Dextrose 5% in liver disease, the orders for D5NSS
9:00am Dextrose 5% in Normal Normal Saline Solution. response to D5NSS administration.
Saline Solution. It's Its purpose is to provide might be monitored
commonly used for fluid hydration and glucose to closely. Since liver  Assess the
resuscitation, electrolyte patients who may be function can affect patient's fluid and
balance, and to provide dehydrated or require glucose metabolism and electrolyte status.
some calories in patients additional glucose in fluid balance, the  Prime IV tubing
who are unable to eat or their system. It's response could vary. with D5NSS
drink. commonly used in They may experience solution according
medical settings for improved hydration to hospital
various purposes, status, but the protocol.
including fluid administration of glucose
resuscitation, electrolyte might need careful  Monitor infusion
imbalances, and as a monitoring, as rate and adjust as
vehicle for administering individuals with liver necessary.
medications. disease can be more
susceptible to glucose
fluctuations. Additionally,
electrolyte imbalances
should be monitored, as
liver disease can affect
electrolyte levels.
Overall, the response
would depend on the
individual's liver function,
overall health status,
and any concurrent
treatments or
medications they are
receiving.
 C. MEDICATIONS

Indication / Specific
Generic and Brand Dosage, frequency and Side effect and
Classifications action / Mechanism of Nursing consideration
name preparation Adverse reactions
action
Generic Name: Aldosterone Antagonist, Aldactone Dosage:  skin rash, Do not give any new
Spironolactone
Selective, Diuretiz, (spironolactone) is an Aldactone is available in  headache, medication during
Brand Name: Postassium - Sparing aldosterone receptor 25, 50 and 100 mg  dizziness, therapy without
Aldactone
antagonist that causes tablets.  nausea, consulting the physician
the kidneys to remove (40mg) Instruct to take
 vomiting,
water and sodium from (Tablet 1/2 tab) medication exactly as
 gas, and
the body, with reduced directed and not to
 stomach pain.
losses of potassium. Frequency: increase dose. And
Aldactone is used to TID (3x a day) instruct that it may take
reduce edema caused days before noticeable
by heart, liver or kidney Preparation: relief
problems, high blood Oral monitor potassium levels
pressure (hypertension), due to its potassium-
and certain patients with sparing effect, assessing
hyperaldosteronism. for signs of
Aldactone is available in hyperkalemia such as
a generic form named muscle weakness or
spironolactone. irregular heartbeat,
educating patients on
maintaining consistent
potassium intake, and
 advising them to report
any adverse effects
promptly. Additionally,
it's essential to monitor
blood pressure and fluid
balance, especially in
patients with heart
failure or hypertension.

Indication / Specific
Generic and Brand Dosage, frequency and Side effect and
Classifications action / Mechanism of Nursing consideration
name preparation Adverse reactions
action
Generic Name: Furosemide is a loop Furosemide is a potent Dosage: Anemia When administering
Furosemide
diuretic used to treat loop diuretic that acts on Injectable solution Diarrhea furosemide, nurses need
Brand Name: hypertension and edema the kidneys to ultimately Dizziness to consider factors such
Lasix, Furoscix
in congestive heart increase water loss from 10mg/mL Excess sugar in the as the patient's fluid and
failure, liver cirrhosis, the body. It is an Oral solution urine electrolyte balance,
renal disease, and anthranilic acid Glucose intolerance blood pressure, renal
hypertension. derivative. Furosemide 10 mg/mL Headache function, and any other
is used for edema Tablet Hearing impairment medications the patient
secondary to various Hives is taking. Monitoring for
clinical conditions, such 20 mg Increased patent ductus signs of dehydration,
as congestive heart arteriosus during the electrolyte imbalances
failure exacerbation, 40 mg neonatal period (especially potassium),
liver failure, renal failure, 80 mg Loss of appetite and hypotension is
and high blood pressure. ( 10mg IV) Low blood calcium crucial. It's also essential
It mainly works by MID and post albumin Low blood magnesium to educate patients
inhibiting electrolyte Frequency: Low blood pressure about the potential side
reabsorption from the Infants and children: (hypotension) effects and the
kidneys and enhancing 1-2 mg/kg IV/IM/orally Muscle cramps importance of taking the
the excretion of water once initially; increased Nausea medication as
from the body. by 1-2 mg/kg every 6-8 Photosensitivity prescribed. Regular
Furosemide has a fast hours (orally) or 1 mg/kg Rash assessment and
onset and short duration every 2 hours (IV/IM); Restlessness communication with the
of action and has been individual dose not to Ringing in the ears healthcare team are key
used safely and exceed 6 mg/kg Severe allergic reactions to ensuring safe and
effectively in both (anaphylaxis) effective use of
pediatric and adult Preparation: Urinary frequency furosemide.
patients. The use of I.V Vertigo
furosemide is particularly Weakness
beneficial in clinical
settings that require a
drug with a higher
diuretic potential. In
addition to oral
formulations, the
solution for intravenous
 and intramuscular
administration is also
available, which is
typically limited to
patients who are unable
to take oral medication
or for patients in
emergency clinical
situations.

Indication / Specific
Generic and Brand Dosage, frequency and Side effect and
Classifications action / Mechanism of Nursing consideration
name preparation Adverse reactions
action
Generic Name: Albumin human is a Albumin IV is a Dosage: nausea, Assess the patient's
Albumin purified form of human prescription medication (20% 50ml) vomiting, serum albumin levels,
serum albumin used to used to treat Acute Liver Adult and pediatric fever, overall nutritional status,
Brand Name: replace lost albumin in Failure, Adult dosage chills, fluid balance, and
Albuked, Albuminex, patients with Respiratory Distress Injectable solution fast heart rate, medical history to
Alburex, Alburx, hypoalbuminemia, to Syndrome, Burns, mild rash, and determine the need for
Albutein, Flexbumin, treat hypovolemia and Cardiopulmonary 50mg/mL (5%) flushing (warmth, albumin therapy.
Hizentra, Human ascites, and as a part of Bypass, 250mg/mL 25%) redness, or tingly
Albumin Grifols, some diagnostic imaging Hypoalbuminemia, feeling) Monitor vital signs, fluid
Kedbumin, Octalbin, kits. Hemodialysis, Frequency: balance, urine output,
Plasbumin, Hypovolemia, Ovarian Q2hrs and signs of fluid
Plasmanate Hyperstimulation overload or depletion
Syndrome. before, during, and after
Preparation: albumin administration.
I.V
Via infusion pump Q12 Ensure compatibility with
for 2 dose other medications or
solutions being
administered
concurrently.
Administer albumin
according to the
healthcare provider's
orders, following proper
dilution and infusion rate
protocols to prevent
adverse reactions.
Monitor for signs of
allergic reactions, such
as rash, itching,
swelling, or difficulty
breathing, and be
prepared to intervene
promptly if they occur.
Document the indication
for albumin therapy,
dose administered,
infusion rate, patient's
response, and any
adverse reactions in the
patient's medical record.
Educate the patient and
their caregivers about
the purpose of albumin
therapy, potential side
effects, and the
importance of reporting
any adverse reactions
promptly.
Follow up with the
patient to assess the
effectiveness of albumin
therapy and adjust the
treatment plan as
needed based on the
patient's response and
clinical condition.
D. DIET

TYPE OF DIET GENERAL DESCRIPTION INDICATION OR PURPOSE NURSING RESPONSIBILITIES

Clear Liquid Diet A clear liquid diet is a temporary eating Following a cesarean section, the ● Monitor vital signs, hydration
plan that consists of liquids that are digestive system may need time to status, and gastrointestinal
transparent and leave little to no residue recover from the effects of anesthesia function, including bowel
in the gastrointestinal tract. This diet is and surgery. A clear liquid diet sounds and any signs of
often prescribed for medical purposes, provides easily digestible fluids that abdominal discomfort or
such as before certain medical are gentle on the digestive system, distention.
procedures, surgeries, or when helping to prevent nausea, vomiting,
recovering from gastrointestinal issues. and discomfort during the immediate ● Assess the patient's
postoperative period. Furthermore, understanding of the clear
Anesthesia and pain medications used liquid diet and their ability to
during and after a cesarean section comply with the prescribed
can sometimes cause nausea and dietary restrictions.
vomiting. Clear liquids help prevent
these symptoms by providing ● Monitor the patient's intake
hydration without putting additional of clear liquids, ensuring that
stress on the stomach. they are consuming an
adequate amount to
maintain hydration.
 TYPE OF DIET GENERAL DESCRIPTION INDICATION OR PURPOSE NURSING RESPONSIBILITIES

Soft Diet A soft diet is a type of eating plan that After surgery, the gastrointestinal ● Assess the patient's ability
consists of foods that are easy to chew, tract may be sensitive, and the patient to chew and swallow, any
swallow, and digest. This diet is often may experience discomfort or discomfort or pain
recommended for individuals who have difficulty with digestion. A soft diet experienced during eating,
difficulty with chewing or swallowing, as minimizes stress on the digestive and any dietary preferences
well as for those recovering from certain system by providing foods that are or restrictions.
medical procedures or surgeries, easier to process and absorb. Soft, ● Explain the purpose of the
including cesarean section (CS). easily digestible foods can support soft diet, including its role in
the body's healing process by postoperative recovery,
providing essential nutrients ease of chewing and
necessary for tissue repair and swallowing, and promotion
recovery. of healing.
● Ensure that the patient has
access to appropriate soft
foods, including options
from different food groups
such as fruits, vegetables,
grains, proteins, and dairy.
● Monitor the patient's intake
of soft foods, ensuring that
they are consuming an
adequate amount to meet
their nutritional requirements
and promote healing.
 E. Activity

TYPE OF ACTIVITY GENERAL DESCRIPTION INDICATION OR PURPOSE NURSING RESPONSIBILITIES

Bed Rest Bed rest is a medical Bed rest allows the body to recover ● Conduct thorough assessments of the CS

intervention that involves from the stress of surgery, patient's vital signs, incision site, pain level,

restricting a patient's including wound healing, tissue urinary output, bowel function, and overall well-

physical activity by requiring repair, and restoration of energy being to monitor for signs of complications and

them to remain in bed for a levels. Also, Bed rest helps ensure timely intervention.

specified period. It is often minimize the risk of complications

prescribed by healthcare such as wound dehiscence (wound ● Monitor the CS incision site for signs of infection,

providers in certain medical opening), infection, bleeding, and hematoma, or dehiscence, and provide

situations to promote deep vein thrombosis (DVT) by appropriate wound care, such as dressing

healing, prevent further limiting physical activity and changes, wound irrigation, and assessment of

complications, or manage allowing the surgical site to heal drainage.

specific conditions. undisturbed.

● Document all assessments, interventions, patient

responses, and vital signs accurately and

promptly in the patient's medical record to ensure

continuity of care and communication among

 healthcare team members.

Ambulation Ambulation for a cesarean ● Ambulation helps prevent ● Conduct a thorough assessment of the CS

section (CS) patient involves complications such as deep patient's readiness for ambulation, including their

the gradual and safe vein thrombosis (DVT), vital signs, pain level, mobility status, incision

movement of the patient urinary retention, healing, and any contraindications or

from bed to walking, constipation, atelectasis, precautions. Assess the patient's ability to

typically initiated in the and pneumonia by tolerate sitting up, standing, and walking, and

immediate postoperative promoting circulation, consider the use of pain medication or analgesia

period. It includes assisting improving lung expansion, as needed.

the patient in sitting up, and facilitating normal bowel ● Provide physical assistance and support as

standing, and walking short and bladder function. needed to help the CS patient with ambulation,

distances to promote transfers, and mobility exercises. Offer

circulation, prevent ● Ambulation supports the encouragement, reassurance, and guidance to

complications, and facilitate recovery process by promote confidence and independence in

recovery following surgery. promoting mobilization, walking. Use appropriate assistive devices such

restoring normal movement as a walker, cane, or abdominal binder to support

 patterns, reducing pain and mobility and protect the incision site.

stiffness, and enhancing ● Ensure a safe ambulation environment by

overall well-being. removing obstacles, providing adequate lighting,

● Ambulation can help and maintaining close supervision during

alleviate discomfort ambulation sessions, especially for CS patients

associated with who may be at risk of falls or balance impairment.

postoperative recovery, Implement fall prevention strategies and use

such as gas pain, bloating, appropriate mobility aids to support stability and

and incisional pain, by prevent injury.

promoting gentle movement Educate the CS patient and their family members about

and circulation. the importance of ambulation, proper walking

techniques, and postoperative care instructions. Provide

instructions on incision care, pain management, and

activity restrictions to promote safe and effective

recovery following surgery.

 F. SURGICAL MANAGEMENT (TUBAL LIGATION AND LOW TRANSVERSE CESAREAN
SECTION)

I. Definition of operation

Tubal Ligation:

Tubal ligation, often known colloquially as "getting your tubes tied," is a highly successful surgical

method for contraception. It entails the severing, blocking, or sealing of the fallopian tubes to impede

the fertilization of eggs by sperm. The term "tubal" pertains to the fallopian tubes, while "ligation"

denotes tying or removing. During this procedure, the fallopian tubes are either severed and tied

using a specialized thread (suture) or obstructed with a clamp, clip, or band. During this surgery, the

fallopian tubes most often are cut and tied to prevent pregnancy for the rest of your life.

SURGICAL MANAGEMENT

Pre-operative Management:

● Patient Education:

Provide comprehensive education to the patient about the cesarean delivery

procedure, including what to expect before, during, and after surgery. Emphasize the

importance of glycemic control and adherence to any pre-operative fasting guidelines.

● Assessment:
 Perform a thorough assessment of the patient's medical history, including their diabetes

management, current blood glucose levels, medication regimen, allergies, and any

other relevant factors.

● Preparation:

Assist in preparing the patient for surgery, which may involve tasks such as starting an

intravenous (IV) line, administering pre-operative medications as ordered (such as

antibiotics or antacids), and ensuring that the patient is in a suitable physical and

emotional state for surgery.

Intraoperative Management:

● Assistance with Anesthesia:

Collaborate with the anesthesia team to prepare the patient for anesthesia

administration. Provide support to the patient during the administration of regional or

general anesthesia, ensuring their comfort and safety.

● Monitoring:

Continuously monitor the patient's vital signs, including blood pressure, heart rate,

respiratory rate, and oxygen saturation, throughout the surgical procedure. Be vigilant

for any signs of complications, such as hypoglycemia, hyperglycemia, or adverse

reactions to anesthesia.

● Assist Midwives:

Assist the surgical team as needed during the cesarean delivery procedure, which may

involve tasks such as positioning the patient, handing instruments to the midwife, and

providing suction or other assistance as required.

Post-operative Management:

● Recovery:

Care for the patient in the immediate post-operative period, ensuring their comfort and

safety as they recover from anesthesia and surgery. Monitor for any signs of post-

operative complications, such as bleeding, infection, or respiratory distress.

● Pain Management:

Administer pain relief medications as ordered and provide non-pharmacological pain

management techniques to help alleviate discomfort. Monitor the patient's response to

pain management interventions and advocate for adjustments as needed.

● Blood Glucose Monitoring:

Continuously monitor the patient's blood glucose levels in the post-operative period, as

directed by the healthcare provider. Administer insulin or other medications as ordered

to maintain glycemic control and prevent complications related to diabetes.

● Support and Education:

Provide emotional support and reassurance to the patient and their family members,

addressing any concerns or questions they may have about the surgery, recovery

process, or diabetes management. Offer education on post-operative care, including

wound care, activity restrictions, and signs of potential complications.

VI. NURSING MANAGEMENT (NURSING CARE PLAN)

Assessment Nursing Diagnosis Scientific Rationale Short-term and Nursing Rationale Expected outcome
Long-term Interventions
Objectives

Subjective Data: Ineffective breathing Short term: Independent:  To provide The Patient will;
The patient’s
“nahihirapan po pattern related to After 2 hours of  Raise side rails. patient safety
inspiration and
akong huminga” as ascites AEB nasal interventions the  Auscultate the  To determine if  Establish and
expiration does not
verbalized by the flaring and use of patient will be able to back and chest of there are maintain effective
provide adequate
patient. accessory muscles establish a normal, the patient. presence of respiratory
ventilation
to breathe. effective respiration.  Position the obstructions or pattern
patient into a secretions  Verbalize
Objective Data: fowler’s position.  To promote lung awareness
(+) Nasal flaring Long term:  Educate the expansion regarding proper
(+) Use of accessory After 24 hours of patient regarding  Overfeeding may coping behaviors,
muscles intervention the not overfeeding interrupt in avoiding risk of
patient will maintain  Provide health breathing and Ineffective
Vital signs effective respiration teaching about may increase risk breathing, and
Temp – 36.5°C and will verbalize proper of aspiration breathing
BP: 110/80 mmHg understanding of positioning and  To promote exercises
PR: 102 bpm proper coping breathing patient
RR: 26 bpm behaviors, avoiding exercises e.g., knowledge
O2 – 95% risk of Ineffective sitting in a regarding the
breathing, and fowler’s position exercises and
 breathing exercises and Pursed lip management of
breathing ineffective
breathing

Collaborative:  To provide
 Administer support on
Oxygen respiration

Administer
medications e.g. To promote lung
bronchodilators expansion and
deeper respirations

Assessment Nursing Diagnosis Scientific Rationale Short-term and Nursing Rationale Expected outcome
Long-term Interventions
Objectives
Subjective Data: Short term: Independent:  To promote The patient will;
Decreased activity The patient has
“hindi ko po kayang After 2 hours of  Provide health patient
tolerance related to insufficient teaching on the
tumayo mag-isa” as interventions the knowledge the  Verbalize
insufficient muscle endurance to significance of
verbalized by the patient will be able to light and sitting benefits of understanding of
mass and ascites complete required or
patient. verbalize activities or ambulation and developing health
AEB verbalization of desired daily ambulation and
understanding of health risks of risk
inability to stand activities the risk of
Objective Data: developing health developing a prolonged activity accompanying
alone
risk accompanying weakness that intolerance prolonged activity
can increase
Vital signs prolonged activity intolerance
patient’s risk for
Temp – 36°C intolerance falls and injuries  To provide
BP: 110/80 mmHg due to examples of
inadequate Participate in
PR: 95 bpm Long term: exercise that the
muscle mass. conditioning or
RR: 20 breaths per After 24 hours of patient can
rehabilitation
minute intervention the  Educate the perform.
program to enhance
O2 – 98% patient will be able to patient regarding
light activities ability to perform
participate in  To assess the
that the patient ADL and identify
conditioning or can perform e.g., patient’s ability in
alternative ways to
rehabilitation chest stretch, executing
upper-body twist, maintain desired
program to enhance activities
hip marching, activity level
ability to perform and ankle stretch,
identify alternative and neck  To help minimize
ways to maintain rotation.
frustration and
desired activity level encourage
 Monitor vital
signs before, motivation to the
during and after
 performing light patient
rehabilitation
activities
To develop
 Make use of
individually
therapeutic
words while appropriated
performing light therapeutic regimen.
rehabilitation
activities.

Collaborative:
 Refer to a
physical therapist

Assessment Nursing Diagnosis Scientific Rationale Short-term and Nursing Rationale Expected outcome
Long-term Interventions
Objectives
Subjective Data: Short term:  Assist John in  Proper The Patient will;
Acute Pain related to Liver pain may
“masakit po yung After 4 hours of finding a positioning helps
complications of sometimes radiate
bandang tiyan ko” as interventions, the comfortable reduce pressure
chronic liver disease, and cause Verbalize awareness
verbalized by the pain of the patient position that on the affected
such as ascites and discomfort in the of understanding of
patient. pain will subside. relieves area, minimizing
hypoalbuminemia. area of the ribs, the pain and how to
pressure on discomfort and
particularly the right relieve it and coping
the abdomen promoting
upper abdomen. the pain
Objective Data: Long term: due to relaxation.
(+) facial grimace After 8 hours of ascites.
(+) pain scale of 7 intervention, the Elevate the  Heat therapy
patient will verbalize head of the helps increase
Vital signs the understanding of bed slightly to blood flow to the
Temp – 36.5°C the pain and how to promote affected area,
BP: 110/80 mmHg relieve it and coping respiratory relieving muscle
PR: 102 bpm the pain comfort. tension and
RR: 26 bpm providing
O2 – 95%  Apply warm localized pain
compresses relief.
PAIN SCALE – 7-10
or heating
pads to the
Comfort measures
affected area
enhance John's
as tolerated to
overall sense of well-
alleviate
being and help
discomfort
alleviate stress and
 and promote
anxiety, contributing
muscle
to pain relief.
relaxation.

Provide comfort
measures such as
gentle massage,
back rubs, or
soothing music to
promote relaxation
and alleviate
tension.

Assessment Nursing Diagnosis Scientific Rationale Short-term and Long- Nursing Interventions Rationale
term Objectives

Subjective Data: “di Short term:  Monitor fluid  Controlling fluid

Impaired Liver Function the production of clotting
siya makaihi ng After 4 hours of intake and output balance is crucial in
related to chronic liver factors and other
maayos” as verbalized interventions, the patient closely to prevent managing ascites
by the patient. will be able to urinate dehydration or and preventing
disease secondary to proteins, detoxification of
more properly. fluid overload further strain on the
autoimmune hepatitis harmful products of
complications. liver.
type 1 and Wilson's metabolism, and
Objective Data:
disease. excretion of bile.
(+) facial grimace Long term:  Consider enteral  Proper nutrition
(+) body malaise After 8 hours of or parenteral supports liver
(+) dipped intervention, the patient nutrition if oral function and helps
will understand and intake is prevent malnutrition,
verbalize the importance insufficient. which can
Vital signs of the right nutrient and exacerbate liver
Temp – 36.5°C monitoring of fluid intake  Provide disease
BP: 110/80 mmHg to avoid impaired liver information on complications.
PR: 102 bpm function. dietary
RR: 26 bpm restrictions and
Empowering the patient
O2 – 95% lifestyle
and family with
modifications to
PAIN SCALE – 7-10 knowledge promotes
support liver
active participation in the
health.
management of the
condition and improves
outcomes.

Assessment Nursing Diagnosis Scientific Rationale Short-term and Long- Nursing Interventions Rationale
 term Objectives

Subjective Data: “para Short term:  Monitor daily  Regular

pong lumalki ang tiyan Fluid Volume Excess Chronic liver disease After 4 hours of weights and assessment helps
and namamaga po and related to peripheral fluid causes cell destruction interventions, the patient abdominal girth to in early
paa” as verbalized by as evidenced by and fibrosis of hepatic will be verbalized track changes in identification of
the patient. peripheral edema tissue understanding on proper fluid status. fluid volume
increased abdominal food selection like low excess and
girth sodium diet.  Encourage small, guides
Objective Data: frequent meals to intervention.
(+) Weight gain promote digestion  Elevating the
(+) edema Long term: and minimize lower extremities
After 8 hours of abdominal facilitates venous
intervention, the patient distension. return, reducing
Vital signs will demonstrate peripheral edema.
Temp – 36.5°C stabilizing fluid volume
BP: 110/80 mmHg and decreased edema Encourage frequent Restricting sodium
PR: 102 bpm position changes to intake and optimizing
RR: 26 bpm prevent skin breakdown protein intake help
O2 – 95% and improve comfort. manage fluid volume
excess and support
PAIN SCALE – 7-10 overall nutritional status.

VII. DAILY PATIENT’S RECORD/ EVALUATION

DAYS ADMISSION Day 1 Day 2 DISCHARGE

Nursing Problems Operation Preparation Acute Pain Pain due to Incision

 BP – 130/80 BP – 120/80 BP – 130/80 BP – 120/80
Vital Signs T: 36.5 T: 36.4 T: 36.1 T: 36
PR: 93 PR: 89 PR: 87 PR: 88
RR: 20 RR: 20 RR: 20 RR: 20

O2: 97 O2: 98 O2: 96 O2: 97

Laboratory Procedures Ultrasound, Complete Blood

Count (CBC), Prothrombin
Time (PT), Blood Chemistry
Test

@6:40 AM @12:00 am @8:30 am

IVF - 1L D5LRS - 1L D5LRS 8 hrs with 10 - 1L PNSS
@9:33 AM units of Oxytocin @12N
- 1L D5LRS
@4:00 PM - 1L PNSS

- 1L D5LRS 8 hrs with 10

units of Oxytocin

 Ranitidine 50mg IV  Tramadol 5mg IV q6 4 Doctors Order:

DRUGS  Tramadol 50mg IV doses Celecoxib 200mg/ PO q12
 Metoclopramide 10mg Iv  Diclofenac 75mg/ SIVP - May resume thyroid
q8 q12 2 doses maintenance and insulin.

Diclofenac 75mg q8 3 doses Tramadol + Paracetamol 1

cap/PO q8

NPO
DIET NPO @6pm Soft Diet once with flatus DAT

- may have a clear liquid diet.

ACTIVITY Bed Rest Ambulation

Vlll. DISCHARGE PLANNING

General Condition of the Client Upon Discharge

During the hospital visit, the patient was seated on the bed accompanied by his mother, and

awake. Despite encountering a degree of unease caused by the CLD the patient displays

determination to get proper treatment and return at the comfort of their home.

A. Methods

MEDICATIONS

 Instruct the patient's mother to watchfully continue and administer all the prescribed

medications by their physician on right time with right dosage.

 Advise the patient's mother to note any changes or side effects when taking the medication.

 Instruct the mother of the patient to constantly monitor the condition of the patient if there is

any presence of exacerbation or changes in the patient's functioning.

EXERCISE

Advanced liver disease can lead to muscle wasting and people can become frail at an earlier

age. Being physically active is an important way to help keep the muscles and body strong. Do what

the patient can manage each day – doing something, even something small, is much better than

nothing. The NHS recommend doing at least 2½ hours of moderate aerobic activity (cardio) each

week and to do strengthening exercises on 2 days of every week. Make a start by doing what the

patient can. Start gently and build up slowly over time. Walking and seated exercises are good places

to start, especially if the patient have symptoms like being easily tired (fatigue) (Physical Activity and

Exercise, 2024).

1. Chest stretch This stretch is good for posture.

A. Sit upright and away from the back of the chair. Pull your
shoulders back and down. Extend your arms out to the side.

B. Gently push your chest forward and up until you feel a stretch
across your chest.

Hold for 5 to 10 seconds and repeat 5 times.

 2. Upper-body twist This stretch will develop and maintain flexibility in the upper back.

A. Sit upright with your feet flat on the floor, cross your arms and
reach for your shoulders.

B. Without moving your hips, turn your upper body to the left as far
as is comfortable. Hold for 5 seconds.

C. Repeat on the right side.

Do 5 times on each side.

3. Hip marching This exercise will strengthen hips and thighs and improve flexibility.

A. Sit upright and do not lean on the back of the chair. Hold on to
the sides of the chair.

B. Lift your left leg with your knee bent as far as is comfortable.
Place your foot down with control.

C. Repeat with the opposite leg.

Do 5 lifts with each leg.

4. Ankle stretch This stretch will improve ankle flexibility and lower the risk of
developing a blood clot.

A. Sit upright, hold on to the side of the chair and straighten your
left leg with your foot off the floor.

B. With your leg straight and raised, point your toes away from you.

C. Point your toes back towards you.

Try 2 sets of 5 stretches with each foot.

5. Neck rotation This stretch is good for improving neck mobility and flexibility.

A. Sit upright with your shoulders down. Look straight ahead.

B. Slowly turn your head towards your left shoulder as far as is

comfortable. Hold for 5 seconds and return to the starting position.

C. Repeat on the right.

Do 3 rotations on each side.

HEALTH TEACHINGS

1. Obtain lots of bed rest. Rest every time you can.

2. Refrain from too much physical activity like lifting heavy items that can lead to injury.

3. Instruct the patient to ask for assistance when needed.

4. Instruct the mother of the patient to administer medicines exactly as directed.

5. Instruct the mother to follow up with the healthcare provider and educated regarding the

significance of follow up checkups and listening to medical advices of healthcare provider.

6. Instruct the mother to monitor the patient’s condition if there is presence of exacerbation and

encourage the mother to not wait until the patient’s condition gets worse before going to the

hospital.

7. Instruct the mother to provide nutritious foods aligned with the type of diet prescribed to the

patient.

8. Instruct the mother to always clean the environment of the patient to prevent contracting any

infections due to low immunity.

9. Instruct the mother to provide the patient loose comfortable clothing namely; sando and shorts to

prevent discomfort, overheating, and allow proper blood circulation.

10. Encourage mother to support light activities and display a cheerful approach if possible, to

promote exercise and uplifting attitude.

11. Learn to read labels on cans and packaged foods to avoid salt.

12. Call your healthcare provider right away if you have any of the following:

 Fever of 100.4°F (38.0°C) or higher, or as directed by your provider.

 Extreme tiredness (fatigue), weakness, or lack of appetite

 Vomiting (with or without blood)

 Yellowing of your skin or eyes (jaundice)

 Itching

 Swelling in your belly or legs

 Black or tarry stools

 Skin that bruises easily

 Confusion or trouble thinking clearly.

OUTPATIENT FOLLOW UP

 A follow up checkup must be done as per the advice of the physician.

DIET

 High calorie

 Lean protein
  Fruits and vegetables

 Avoid uncooked meats

 Low salt

 Well-balanced diet

 Low copper

a. Chronic Liver disease

 Dietary changes for liver disease may involve:

 Increasing your intake of carbohydrates to be in proportion with the amount of protein you eat.

 Eating fruits and vegetables and lean protein such as legumes, poultry, and fish. Avoid

uncooked shellfish due to the risk of hepatitis A.

 Taking vitamins and medicines prescribed by your health care provider for low blood count,

nerve problems, or nutritional problems from liver disease.

 Limiting your salt intake. Salt in the diet may worsen fluid buildup and swelling in the liver.

b. Autoimmune Hepatitis type 1

Researchers have not found that eating, diet, and nutrition play a role in causing or preventing

autoimmune hepatitis. Patients that have autoimmune hepatitis, should eat a healthy, well-balanced

diet. A healthy diet is also important if autoimmune hepatitis leads to cirrhosis.

c. Wilson Disease

People with Wilson disease must follow a diet that is low in copper. Foods to avoid include beef liver,

cashews, black-eyed peas, vegetable juice, shellfish, mushrooms, and cocoa. People with this

disease should not take any vitamin or mineral supplement that contains copper.

d. Ascites

Limiting sodium in your diet is crucial for treating ascites. For people with ascites, recommended

sodium intake is less than 2,000 to 4,000 milligrams a day.

e. Hypoalbuminemia

Taking vitamins (vitamin D) and eating a well-balanced diet with whole-grain carbohydrates (bread

and rice) can increase the amount of albumin your body produces.
Foods Allowed on Soft Diet

Fruits and vegetables

 Canned fruit

 fruits (Bananas, melons, mangoes)

 Baked fruits (Baked apple)

 Steamed vegetables

 Chop suey

Carbohydrates

 Mashed potato

 Rice Porridge (Lugaw)

 Bread

 Oats

 Pasta

Proteins

 Soft tofu

 Creamy peanut butter

 Baked beans

 Yoghurt

 Poultry

 Fish

7 DAY MEAL PLAN

DAY 1
Breakfast: Lunch: Dinner:
Rice porridge Chop suey Vegetable broth soup

DAY 2
Breakfast: Lunch: Dinner:
Jam sandwich Oatmeal with bananas Chicken salad
DAY 3
Breakfast: Lunch: Dinner:
Mashed banana Tinola Macaroni soup

DAY 4
Breakfast: Lunch: Dinner:
Egg sandwich Mashed banana Tuna sandwich

DAY 5
Breakfast: Lunch: Dinner:
Baked beans with bread Oatmeal with mango Sinigang na bangus

DAY 6
Lunch:
Breakfast: Dinner:
Mashed potatoes with
Papaya Vegetable salad
chicken

DAY 7
Breakfast: Lunch: Dinner:
Pancakes Oatmeal Vegetable broth soup

Food items that should be avoided

 Don’t eat foods high in fat, sugar, and salt. Stay away from alcohol, a lot of fried foods

including fast food restaurant meals. Raw or undercooked shellfish such as oysters and clams.

IX. SUMMARY OF FINDINGS

On March 25, 2026, a 36-year-old patient was brought to the maternity unit, pregnant with a

boy fetus at 36 weeks and 2 days AOG. She was planned to deliver the baby via Caesarean delivery.

The patient was diagnosed with hypothyroidism, a disorder in which the thyroid gland does not

produce sufficient thyroid hormone. This illness is also known as underactive thyroid. In the early

stages, hypothyroidism may not produce any visible symptoms. Untreated hypothyroidism can lead to

a variety of health issues, including excessive cholesterol and cardiac difficulties. Diabetes, a chronic

metabolic condition characterized by increased levels of blood glucose (or blood sugar), can cause

catastrophic damage to the heart, blood vessels, eyes, kidneys, and nerves. The most common is

type 2 diabetes, which mainly affects adults and arises when the body develops insulin resistance or

fails to produce enough insulin. She was also diagnosed with Tourette syndrome, a neurological
system disorder. TS produces "tics" in humans. Tics are quick twitches, gestures, or sounds that

people repeat. People with tics are unable to stop their bodies from performing these functions. For

example, a person may blink repeatedly. The patient has a history of hypertension. Because her

pregnancy was considered high-risk, her attending physician recommended that she have a

Caesarean birth. A healthy baby boy was born safely on March 26, 2024.

To summaries, despite the patient's complex medical history, which included hypothyroidism,

diabetes, Tourette syndrome, and hypertension, the decision to proceed with a Caesarean delivery

was taken in the best interests of her and her baby's health. This strategy reduced the dangers

associated with her high-risk pregnancy, resulting in the safe delivery of a healthy baby boy on March

25, 2024.

X. RECOMENDATION/S AND CONCLUSION

The recommendation is a close monitoring of John's clinical status, including liver function,

fluid balance, and nutritional status, is crucial for timely intervention and treatment optimization. A

multidisciplinary team comprising hepatologists, pediatricians, nutritionists, and other specialists

ensures tailored and holistic care. Collaboration facilitates a multidimensional approach

encompassing medical therapy, nutritional support, and potential interventions like paracentesis or

liver transplantation. Effective communication with John's caregivers and family-centered care are

essential for education, emotional support, and treatment adherence. By implementing a structured

and collaborative management strategy, John's healthcare team aims to optimize his clinical

outcomes and enhance his quality of life despite the challenges of his complex pediatric liver disease.

Based on the presented case scenario of John Patrick Canlas Nunez, an eight-year-old

pediatric patient admitted to the pediatric unit of Jose B. Lingad Memorial General Hospital with a

history suggestive of chronic liver disease, likely autoimmune hepatitis type 1 or Wilson disease, his

condition poses significant challenges requiring specialized care and close monitoring. The

importance of John's condition, characterized by massive ascites and hypoalbuminemia, highlights

the severity and advanced stage of his liver disease. These symptoms indicate potential

complications such as hepatic decompensation and portal hypertension, emphasizing the critical

need for comprehensive assessment and management.

 Upon admission, John underwent a series of tests, including hematological, biochemical, and

chemistry assessments. These diagnostic investigations aimed to elucidate the extent of his liver

pathology, assess hepatic function, and evaluate any associated complications or comorbidities. The

results of these tests are pivotal in guiding the formulation of an individualized treatment plan tailored

to address John's specific needs and optimize his clinical outcomes. In conclusion, the case of John

Patrick Canlas Nunez exemplifies the intricate nature of pediatric liver diseases and the imperative for

specialized care in managing such complex conditions. Through meticulous evaluation and

multidisciplinary collaboration, healthcare providers can effectively navigate the challenges posed by

chronic liver disease in pediatric patients, striving to improve outcomes and enhance quality of life.

XI. LEARNING DERIVED

Escobar, Myrna

In patients with chronic liver disease probably secondary to autoimmune hepatitis type 1,

Wilson disease massive ascites secondary to consider hypoalbuminea, learning about diagnostic and

laboratory procedures involves understanding tests like liver function tests (LFTs), imaging studies

(such as ultrasound, CT scan, or MRI), and liver biopsy. In vitro fertilization (IVF) but it's important to

consider the potential risks and consult with specialists. Medication management in these patients

requires careful consideration of liver metabolism and potential drug interactions, so it's crucial to

work closely with healthcare providers experienced in managing liver disease.

Dayrit, Gil Matthew B.

John Patrick Canlas Nunez's case emphasizes the critical aspects of managing pediatric

patients with chronic liver disease. A comprehensive diagnostic workup upon admission, including

hematological and biochemical tests, is crucial to understand the condition's severity and associated

complications. Close monitoring and specialized care by a multidisciplinary team are essential to

tailor a holistic treatment plan, optimize outcomes, and ensure effective communication with

caregivers. Implementing a structured and collaborative approach, including family-centered care, is

key to managing complex pediatric liver diseases effectively, ultimately aiming to improve patient

outcomes and enhance quality of life.

Castro, Maruella

Throughout the study I have acquired an in-depth knowledge regarding the condition of

Chronic Liver Disease (CDL) in a manner which it affects the human body. As well as, the health

conditions which may arise from chronic liver disease such as ascites which is accompanying

complication seen in patients with CDL. Furthermore, I have grasped some understanding pertaining

to the treatment of the diseases in a hospital setting in which I have appreciated and added more

beneficial knowledge to me as a student nurse which I can use to develop my skills and knowledge to

aid people. Ultimately, during the one-day hospital visit, I have appreciated the benefit of nursing,

which is the fulfillment in giving care to children and people in need.

XIl. REFERENCES

https://www.rxlist.com/furosemide/generic-drug.htm
https://www.rxlist.com/albumin/generic-drug.htm
https://www.rxlist.com/aldactone-drug.htm