LIVER CIRRHOSIS

SECONDARY TO SCHISTOSOMIASIS, DIABETES MELLITUS II, ANEMIA 2

INTRODUCTION

Liver Cirrhosis Liver cirrhosis is a term that refers to a group of chronic diseases of the liver in which normal liver cells are damaged and replaced by scar tissue. When scar tissue develops in the liver, the amount of normal liver tissue decreases and the liver is unable to function normally.

Causes Alcoholic liver disease. Chronic hepatitis C. Chronic hepatitis B and D. Autoimmune hepatitis. Inherited diseases. Nonalcoholic steatohepatitis (NASH). Blocked bile ducts. Drugs, toxins, and infections. Severe reactions to prescription drugs, prolonged exposure to environmental toxins, the parasitic infection schistosomiasis, and repeated bouts of heart failure with liver congestion can all lead to cirrhosis.

Symptoms The most common symptoms of liver cirrhosis are: Weakness Exhaustion Loss of appetite nausea Weight loss Dark skin color Intense itching Confusion Nose bleeds

The following are common problems, or complications, caused by cirrhosis. Breast enlargement in men Fluid retention in the legs and abdomen (edema and ascites) Jaundice Gallstones Blood clotting difficulties (bruising and bleeding) Esophagea; vein bleeding Toxins in the blood and brain Sensitivity to medication Portal hypertension Varices

Schistosomiasis
also known as bilharzia, bilharziosis or snail fever Is a parasitic disease caused by several species of tremotodes ("flukes"), a parasitic worm of the genus Schistosoma. Often is a chronic illness that can damage internal organs and, in children, impair growth and cognitive development.

DEMOGRAPHIC DATA

Clients name/initials Sex Age Birthday Birthplace Marital Status Race/Nationality Address

G.P. Male 66 years old August 14, 1944 Dagami, Leyte Married Filipino B-6 L-46 Ph-2B Camella Homes Banlic, Cabuyao, Laguna

Educational Background Occupation Usual source of income Date of Admission Diagnosis

College graduate Retired elementary teacher Pension and son November 18, 2010 Liver Cirrhosis secondary to Schistosomiasis, DM II, Anemia 2

SOURCE AND RELIABILITY OF INFORMATION

The data being presented in this case were obtained from the Dr. Jose P. Rizal Memorial District Hospital, from Nov. 19-20, 2010. The primary information was gathered through interviewing the patient himself and from his son. Secondary information was gathered from the patients chart where in, it contains important data of the patients stay at the hospital. Other information was taken from different books and internet.

REASON FOR SEEKING CARE/CHIEF COMPLAINT

 Pallor

is the main concern of the patients son in bringing his father to the hospital

HISTORY OF PRESENT ILLNESS

 The

patient was experiencing pallor before he was brought to the hospital. He is experiencing body weakness and slight jaundice. With slight edema in his legs

PAST MEDICAL HISTORY

 The

patient was diagnosed with Schistosomiasis when he was a kid way back in his hometown in Leyte. In 196, he was diagnosed with Diabetes Mellitus Type II. Since then he is receiving maintenance medicines to treat his DM.

FAMILY HISTORY

Grandfather Grandfather Grandmother Diabetes Mellitus Grandmother

Father Mother Liver Cirrhosis 57 y/o Diabetes Mellitus 80 y/o

Brother 64 y/o Alive & Well

Brother 61 y/o

Brother

Sister

y/o ellit s

FE ALE

E EASE

LE EN

Patient G. P. ALE Liver Cirrhosis 2 to Schistosomiasis; Diabetis Mellitus; Anemia 2 66 y/o

Alive & Well

ia etes

Alive & Well

2 y/o

FUNCTIONAL ASSESSMENT

Self Esteem/Self Concept/Self Perception

At

his age of 64, patient G. P. has accomplished many things such as providing education to his only son and he has provided his family all the necessary things they need. He was a elementary teacher but now he is on retirement.

Health Perception/Health Maintenance

The

patient gives priority to his health. He seeks medical advice whenever he is sick

Activity/Exercise Pattern
When

he was still teacher, his mode of exercise was through walking to work every morning. His usual routine everyday was school-farm-home. After his work, he usually drop by to their nearby farm, sit there for a while and rest, then after he goes home. His past time is reading and making lessons to his students.

Nutrition/Elimination Process
He

is a health buff person. He prefers to eat fish and vegetables rather than meat. He is not fond of drinking carbonated drinks, only water. has a normal elimination pattern. He defecates everyday and urinates without pain.

He

Sleep/Rest pattern
He

usually has complete sleep everyday and is an early riser. Before he goes to sleep, he makes his lesson plan for school and wakes up at around 5:30-6:00 in the morning.

Intrapersonal relationship
The

patient has a harmonious relationship with his family and other people as well. He doesnt have hard time dealing with other people.

Sexuality/Reproductive Health
He

is proud family man. He was married to his wife at the age of 30 and had one son.

Coping stress management/Tolerance pattern

Whenever

the patient feels stressed out, he usually sleep or go to his farm and unwind a bit. He is a ver private person, he doesnt speak out his problems to anyone, and he rather keeps it to himself.

Personal Habits
He

helps his wife in doing the everyday chores around the house. He washes clothes and cleans outside their house. He is a passive smoker because his wife is an active smoker. He is an occasional drinker, he drinks if there is an occasion or to have bonding with his friends.

Environmental Hazards
Their

house way back in Leyte, is in a village and is near to a farm.

REVIEW OF SYSTEM

Systems General Status

y y y

November 19, 2010 awake, lying in bed conscious weak in appearance T P RR BP T P RR BP 36.4C 63bpm 16cpm 90/60 mmHg 35.9C 73bpm 17cpm 100/60 mmHg
y y y

November 20, 2010 awake, lying in bed conscious weak in appearance

Vital Signs

4pm 8pm

Integument

y y y y y y

Afebrile with temp of 36.4C With yellowish skin color with good skin turgor no lesions present With edema on right leg coherent

36.0C T 60bpm P 18cpm 100/60 RR 4pm mmHg BP 36.2C T 8pm 60bpm P 16cpm RR 90/60 BP mmHg y Afebrile with temp of 36.0C y With yellowish skin color y with good skin turgor y no lesions present y With edema on right leg coherent

Neurological

Gastrointestinal

y Abdominal circumference is 36 y Right abdomen enlarged y Bowel elimination during shift is 1 y DM diet

y Abdominal circumference is 36 y Right abdomen enlarged y Bowel elimination during shift is 1 y DM diet

Genitourinary

y UO during shift is y UO during shift is 1 diaper 4x y With active flexion y With active flexion of extremities of extremities

Musculoskeletal

y y y

HEENT
y y y y

no head injury no lesions noted on head has cataract in both eyes ears are properly aligned no nasal discharges noted with dry cough

y y y y y y

no head injury no lesions noted on head has cataract in both eyes ears are properly aligned no nasal discharges noted with dry cough with normal heart rate of 60 bpm with good capillary refill of 2.0 secs with clear breath sounds on both lungs upon auscultation shallow and rapid breathing pattern RR 18 cpm

Cardiovascular
y

with normal heart rate y of 63 bpm with good capillary refill y of 2.0 secs with clear breath y sounds on both lungs upon auscultation deep and slow breathing y pattern RR- 16 cpm y

Respiratory
y y

ANATOMY AND PHYSIOLOGY

THE LIVER

The LIVER, the largest gland of the body, can be considered a chemical factory that manufactures, stores, alters, and excretes a large number of substances involved in metabolism. The location of the liver is essential in this function, because it receives nutrient-rich blood directly from the gastrointestinal (GI) tract and then either stores or transforms these nutrients into chemicals that are used elsewhere in the body foe metabolic needs

FUNCTIONS
Glucose

Metabolism Ammonia Conversion Protein Metabolism Fat Metabolism Vitamin and Iron Storage Drug Metabolism Bile Formation Bilirubin Excretion

PATHOPHYSIOLOGY

Cercariae

Skin

Venules

Portal veins of the liver

Scar formation

Half of the eggs rest in the body where they scar & damage vital organs

Venous plexus in the bladder

Submucosal veins of the GUT

Inflammation

Fibrotic formation

Atrophy of the Liver

CIRRHOSIS

LABORATORY

HEMATOLOGY NOV. 18, 2010

y

Blood typing

Blood type B (rh +)

BLOOD CHEMISTRY NOV. 19, 2010

Test/Proced Result Normal ure Values BUN 21 7.0-20.0 mg/dl Creatinine 2.0 0.52-1.25 mg/dl Sodium 135.2 137-145 mmol/l Significa nce Increased Nursing Implication

Potassium

3.73

3.6-5.0 mmol/l

acute and chronic intrinsic renal disease Increased renal functional impairment Decreased Dilutional hyponatremia may occur in cardiac failure, liver failure, nephrotic syndrome, malnutrition, and SIADH Normal

SGPT (ALT) Total protein Albumin

92

9-72 u/L

Increased renal functional impairment Normal Decreased malnutrition, malabsorption, liver disease, and other chronic diseases chronic inflammation and in Blymphocyte neoplasms, like myeloma and Waldenstrm's macroglobulinemia chronic inflammation and in Blymphocyte neoplasms, like myeloma and Waldenstrm's macroglobulinemia

6.6 2.2

6.2-8.2 mg/dl 3.5-5.0 mg/dl

Globulin

4.4

2.8-3.2 mg/dl

Increased

A/G ratio

0.5

1.2-1.6

Decreased

HEMATOLOGY NOV. 19, 2010

Procedure/ Test Hemoglobin Result Normal Values Significance Nursing Implication Anemia 81 M: 140-170 g/L F: 120-150 g/L M: 0.42-0.50 F: 0.37-0.47 5-10 x 10 /L Decreased

Hematocrit

0.24

Decreased

WBC

4.8

Decreased

Anemia; hemorrhage, dehydration Infection

RBC

2.9

M: 4.5-5.0 x 10 /L F: 4.0-4.5 x 10 /L

Decreased

Anemia; Bleeding

Differential Ct. Segmenters

0.59

0.55-0.65

Normal

0.41 Lymphocytes Platelet ct. 150

0.25-0.35

Increased

May indicate acute bacterial infection

150-400 x 10 /L

Normal

Red cell indices MCV MCH

82.8 28.1

80-96 fL 27-31 pg

Normal Normal

MCHC

34.0

32-36%

Normal

HEMATOLOGY PT/PTT NOV. 19, 2010

Test/Proced Result Control Normal ure Values INR % Activity Time 1.51 47.7% 16.1 1.10 88.9% 12.4 11.3-13.3 secs Increased Thrombocytopenic purpura, patelet abnormality, vascular abnormality, leukemia, severe liver diselase Liver failure Significa nce Nursing Implication

PTT

38.5

35.7

26-36 secs

Increased

DRUG STUDY

Name of Drug

Classification

Dosage/Route/ Frequency

Indication// CI

Side effects

Mechanism of Action

Nursing Consideration

Generic name: Lactulose

Laxative and ammonia detoxicant

30cc PO QID

Brand name: Duphalac

Date ordered: Nov. 18, 2010

Indication: Treatment of portal systemic (hepatic) encephalopat hy and Treatment of constipation

Cramping, belching, flatulence, foulsmelling stools, increased thirst, abdominal discomfort

Contraindicat ion: Galactose-free dite, abdominal pain, vomiting, appendicitis

Lactulose is a sugar that acidifies the colon, thus preventing the absorption of ammonia. It also acts as a stool softener by increasing the osmotic pressure and pulling water into the colon.

y y y

y y y

Observe changes in the patients mental status, muscle strength and general appearance. Assess for bowel activity Always check the electrolyte reports. Keep accurate records of input and output, daily weights. Anticipate need for low-protein diet. Watch out for signs of diarrhea. Encourage increased fluid intake

Name of Drug Generic name: Furosemide

Classification Loop Diuretic

Dosage/Route/ Frequency 20 mg TIV Q12 with BP prec

Brand name: Lasix

Date ordered: Nov. 18, 2010

Indication/ CI Indication: (1) Edema associated with CHF, nephritic syndrome, hepatic cirrhosis and ascites. (2) IV for acute pulmonary edema (3) PO to treat hypertension in conjunction with spironolacton e, triamterene, and other diuretics except ethacrynic acid Contraindication: Never use with ethcrynic acid. Anuria, hypersensitivity to drug, severe renal disease associated with azotemia and oliguria, hepatic coma associated with electrolyte depletion. Lactation

SE Most Common: Jaundice, tinnitus hearing impairment, hypotension, water/electrolyte depletion, pancreatitis, abdl pain, dizziness, anemia. Electrolyte and Fluid Effect: Dehydration, hypovolemia, thromboembolism GI: Nausea, oral & gastric irritation, vomiting, anorexia Otic: Tinnitus, hearing impairment, reversible deafness CNS: vertigo, headache, dizziness CV: orthostatic hypotension, thrombophlebitis Hematologic: Anemia, thrombocytopenia, leucopenia Allergic: rashes, pruritus, urticaria Miscellaneous: fever, weakness, muscle spasms, urinary frequency

MOA Inhibits the reabsorption of Sodium and Chloride in the paroxysmal and distal tubules as well as the ascending loop of Henle; this results in the excretion of sodium, chloride, and, to a lesser degree, potassium and bicarbonate ions. The resulting urine is more acid. Diuretic action is independent of changes in clients acidbase balance. Has a slight antihypertensi ve effect.

Nursing Consideration y y y Give IV injection slowly over 1-2mins Observe with ototoxicity Monitor BP, wt, breath sounds, I&O, electrolytes; observe for S&S of hypokalemia and edema Take in the morning on an empty stomach to enhance absorption and avoid interruption of sleep. May take with food or milk if GI upset Drug may cause BP drop, Change positions from lying to standing slowly. Avoid alcohol and do not exercise heavily in hot weather Supplement diet with vegetables and fruits that are high in potassium (bananas, oranges, peaches, dried dates)

y y

Name of Drug

Classificat ion Haemostati cs Vit K derivative

Generic name: Vit. K (Phytonadione)

Dosage/Ro ute/ Frequency 1 amp TIV OD X 3 doses

Indication/ Contraindication Indication: Coagulation disorders due to faulty formation of factors II, VII, IX and X when caused by vitamin K activity (1) Anticoagulant -induced prothrombin deficiency (2) Hypoprothrom binemia secondary conditions limiting absorption or synthesis of vitamin K (3) Drug-induced hypoprothrom binemia due to interference with vitamin K metabolism (4) Prophylaxis and therapy of hemorrhagic disease in newborns Contraindication: Severe liver disease

Side effects

Mechanism of Action Vitamin K is essential for the hepatic synthesis of factors II, VII, IX and X, all of which are essential for blood clotting. GI absorption occurs only via intestinal lymphatics and requires the presence of bile salts. Vit K is not effective in reversing the anticoagulant effect of heparin. Frequent determination of PT are indicated during therapy y y

Nursing Consideration

Brand name: Mephyton

Date ordered: Nov. 18, 2010

Most Common: After parenteral use: flushing, sweating, hypotension, dizziness, pain/swelling/te nderness at injection site Allergic: rash, urticaria, anaphylaxis

y y

Mix suspension only with water or D5W. Mix colloidal injection with D5W, isotonic NaCl or D5W/NSS Heparin may be used to reverse effects from over dosage Comply with dietary recommendations Take with food for best absorption and utilization Avoid self-medicating with vitamin supplements that exceeds the RDAs Avoid alcohol, aspirin and ibuprofen compounds (NSAIDs) as well as any other OTC preparations. Report any adverse effects. Store away from heat In tight, light resistant containers, out of childrens reach

PROBLEM LIST

Rank
1

Actual Problem
Edema

Date Identified
Nov 19, 2010

Date resolved

Decreased Albumin level

Nov. 19, 2010

Rank
1 2

Potential Problem
Risk for impaired liver function Risk for impaired skin integrity

Date Identified
Nov. 19, 2010 Nov. 20, 2010

Date resolved

ACTUAL PROBLEM NO.1 EDEMA

Assessment
y y y Edema at the right leg Abdl girth 36 Decreased hgb and hct

Nursing Diagnosis
Fluid volume excess related to retention as manifested pedal edema

Nursing Plan

Nursing Intervention

Rationale

Expected Outcome
Patient will try coughing exercises and deep breathing exercise at bed.

Short Term At the end of the shift, the patient will be able to verbalize understanding of his dietary/fluid restrictions. Long Tern At the end of the patients hospitalization, patients edema will lessen or gone.

y y y y y y y y y

Monitor input and output Monitor for signs of hypovolemia Turn patient every 2 hours Encourage coughing and deep breathing exercises Avoid infection and circulatory infection Maintain patient at rest Measure abdominal girth Auscultate heart tones for S3 ventricular gallop Emphasize frequent oral care

y y y y y

It is important to prevent fluid volume overload Because bleeding may occur To prevent pneumonia To prevent further complication To prevent further complication Because of fatigue, muscle atrophy and wasting For changes may indicate fluid retention/edema To reduce discomfort of fluid restritions

ACTUAL PROBLEM NO. 3 DECREASED ALBUMIN LEVEL

Assessment
y Decreased albumin level of 2.2 Lack of interest in eating

Nursing Diagnosis
Imbalanced Nutrition: Less Than Body Requirements related to inability to absorb nutrients secondary to disease condition

Nursing Plan
Short term At the end of the shift, the patient will be able to demonstrate behaviors, lifestyle changes to regain weight. Long Term At the end of the patients hospitalization, the patient will demonstrate progressive weight gain toward goal. y

Nursing Intervention
Asses contributing factors Determine clients gag reflex and evaluate mouth Discuss eating habits Assess weight Limit fiber Promote pleasant, relaxing environment y

Rationale
To assess what might have triggered the condition It can affect ingestion of nutrients To appeal to patients likes/dislikes To establish baseline parameters It may lead to early satiety To enhance intae of food

Expected Outcome
The patient will verbalize the urge to eat and weight will gain simultaneously

y y y y

y y

POTENTIAL PROBLEM NO 1 RISK FOR IMPAIRED LIVER FUNCTION

Assessment Nursing Diagnosis
Risk for impaired liver function secondary to disease condition

Nursing Plan
Short term At the end of the shift, patient will demonstrate behaviors to reduce risk factors and protect self from injury Long term: At the end of the patients hospitalization. The patient will be free from signs of liver failure y

Nursing Intervention
Educate patient on ways on prevent exposure Emphasize importance of hand hygiene Encourage to avoid intake of alcoholic beverages Encourage to eat nutritious foods Emphasize importance of diet. y

Rationale
To limit damage to liver To prevent complication To prevent complication s To improve immune function To minimize further complication

Expected Outcome
Patient will verbalize the risk factors that may contribute to possible liver damage

y y

PROBLEM LIST

POTENTIAL PROBLEM NO. 2 RISK FOR IMPAIRED SKIN INTEGRITY

Assessment Nursing Diagnosis
Risk for impaired Skin integrity related to impaired metabolic state as manifested by edema

Nursing Plan
Short term At the end of the shift, the patient will demonstrate ways to prevent skin breakdown Long term At the end of the patients hospitalization, the patients skin with edema will return to its normal state. y y y y y

Nursing Intervention
Assess skin routinely Review patients Laboratory Handle client gently Maintain good hygiene Massage bony prominences and use proper positioning Provide adequate clothing Provide protection by use of pillow and soft mattresses and keep bedclothes dry and wrinkle-free Emphasize importance of adequate nutritional/fluid intake Encourage to elevate lower extremities Encourage to do simple activities y y

Rationale
May indicate particular vulnerability Decreased Almbumin may indicate decresed wound healing To avoid bruising To prevent skin breakdown To prevent friction or shear injury To prevent vasoconstriction To increase circulation and limit/eliminate excessive tissue pressure To maintain general good health and skin turgor To enhance venous return To enhance circulation

Expected Outcome
Patient will elevate legs more frequrntly.

y y y y y

y y

y y

y y

1st day Patient G. P. was lying on bed awake with ongoing PNSS 1L that is running KVO. He was weak in appearance but is coherent. He answers to my questions comprehensively He is currently receiving three medications: Furosemide, Lactulose and Vit K. His skin is slightly jaundiced. He can still manage to walk to the comfort room to urinate or defecate.

2nd day Patient was sitting on bed, with the4 same IVF on. There is no new drug ordered but he is now on complete bed rest because he cannot withstand to walk to the bathroom anymore. He uses the bedpan to urinate and defecate.