Navigating the complexities: A case study on chronic liver disease
Objectives
General objective
To collect baseline information from the client
To be able to come up with as understanding of the disease process and formulate a comprehensive Nursing core plan using the specific objective of Nursing process.1, 2, 3, 4, 5, 6, 7, 8
Specific objective
To review the Physiology of the Disease
To understand the path physiology of the disease.
To know the medical treatment such as medications and laboratory works involved.
To know the Nursing Management for the Disease.
To practice nursing assessment during data gathering.
To prioritize identified health problems of the patient.
Introduction
Table 1
Biographic information
|
Name
|
XYZ
|
|
Age
|
70 years
|
|
Sex
|
Female
|
|
Religion
|
Islam
|
|
Education
|
Nil
|
|
Occupation
|
Housewife
|
|
Date of Admission
|
20-04-2022
|
|
Time of Admission
|
10:14:58 Am
|
|
Diagnosis
|
Chronic Liver Disease
|
|
Word
|
3A (Gastroenterology)
|
|
Address
|
XXX
|
|
Marital Status
|
Married
|
|
Information
|
Daughter in law
|
|
Date of Discharge
|
28-04-2022
|
|
MRD No
|
1284759
|
|
Bed No
|
02
|
|
Patient type
|
Emergency
|
Present Chief Complainant (Reason for Hospitalization)
70 Years old female with type 02 Diabetes Miletus (T2DM) had experienced pain in Abdomen with slight fever.
History of present illness
The patient was in her usual state of health when one day she suddenly felt pain in Abdomen of mild intensity with dull aching radiating to back with no aggravating as relieving factors. The patient also had experienced 3-4 episodes of loose stool as 02 episodes of black tarry stools.9, 10, 11, 12, 13
History of past illness
Medical History: The 70 years old is suffering from type 2 Diabetes Mellitus (T2 DM)
Surgical history: Not any
Developmental history
-
Neonatal
Birth Weight: Normal
Birth condition: Stable
-
Toddler
-
Childhood
Growth: Normal
Condition: Stable – No Disease Present
-
Adolescence
Growth /Nutritional needs: Good /fulfilled
Diseased condition: - No Disease Condition found
Adulthood: T2DM
Details of immunization
Immunization: Details not Available
Vaccinated for Covid-19
Family of any illness
The clients both sons have a history of cholelithiasis.
Socio- economic status
Marital Status: Married
No. of children: 02 (Sons)
Total monthly income: 4000-5000/per month
Housing condition: Pacca House
Electricity Facility: Available
Personal history
Diet: Mixed
Hygiene: Satisfactory
Lifestyle: No Significant
Environmental history
Dirking water supply: Tap water
Environmental Sanitation: Acceptable
Waste /excreta disposal: Dumping
Presence of flies/ mosquitoes /rodents: No
Psychosocial history
Language: Kashmiri
Relationship with family members: Good
Social Support: Available
Physical examination
General behavior and appearance:
Orientation: Altered sensorium
Irrelevant Taking
Dress/ Grooming: Satisfactory, appropriate to the climate
Posture/Gait: Lone tone, relevant taking
Activity level Nil
Rapport: - _________
Anthropometry
Height: 5` 4`
Weight: 70 kg
Head to be examination
-
Head
Position: Normal
Size: Normal
Symmetry: Symmetrical
-
Hair as scalp
Quantity: Thin
Dandruff: Absent
Lesion on Scalp: Absent
-
Face
Shape: Round
Symmetry: Symmetrical
Involuntary movement: Absent
-
Eye
Eyebrows: Normal
Eyelash: Normal
Alignment: Well aligned
Eyelid: Puffy
Were glasses: No
-
Ear
Color: Brown
Size: Normal
Angle of attachment: Normal
-
Nose
Symmetry: Symmetrical
Discharge: Not present
-
Mouth
Color of lips: Brownish
Bacall Mucosa: Dry
Teeth: Yellowish
-
Neck
Size: Normal
Symmetry: Normal
Range of Motion: Well
Lymph Nodes: Normal
Systemic Examination
Chest
Inspection
-
Skin: - Normal
No redness but Pallor
Equal movement or both sides
No scars/bulge
No added Sounds
CVS
No murmurs
Heart Rate: 110Bbpm
Abdomen
Inspection
Abdomen distended symmetrically all quadrants moving equally with respiration
Palpation
Hepatomegaly +
Splenomegaly +
Percussion: Ascites +
Auscultation: Bowel Sound +
No bruit
Muscular skeleton system
Normal Tone
No Muscle atrophy
Asteriais
Intergumertary system
Inspection: Skin is wet due to sweating
Palpation: Swelling /mass deducted, edema present
Neurological system
Level of Consciousness: Loss of Consciousness, Altered Sensuous, Irrelevant talking
Vital assessment
Plus Rate: 110Bpm
Spo2: 98%
Blood pressure: 102/56 mmHg
Respiration Rate: 18/min
Table 2
Investigations
|
Investigation
|
Result
|
Reference Range
|
|
RBC
|
2.95
|
4.20-6.50
|
|
HGB
|
7.8
|
12-16
|
|
PLT
|
15
|
150-450
|
|
WBC
|
3.2
|
4-10
|
|
NEUT%
|
76.1
|
40-75
|
|
MOMO%
|
5.6
|
1-10
|
|
BASO%
|
0.2
|
0-1
|
|
EO%
|
0.1
|
1-6
|
Table 3
LFT/KFT
|
Investigation
|
Result
|
Reference Range
|
|
Urea
|
35
|
10-45
|
|
Creatinine
|
0.97
|
0.50-1.50
|
|
Billinubin
|
2.77
|
0.30-1.50
|
|
SGPT/ALT
|
19
|
0-45
|
|
ALP
|
79
|
30-141
|
|
Total Protein
|
6.27
|
5.50-8.50
|
|
Albumin
|
2.97
|
3.50-5.20
|
Disease Condition
Description of disease condition
Chronic liver disease is a disease process of the liver that involves a process of progressive destruction and regeneration of liver parenchyma leading to fibrosis and cirrhosis.14, 15, 16, 17
Chronic liver disease refers to disease of the liver which lasts over a period of six months .It consist of a wide range of liver pathologies which included inflammation (chronic hepatitis) liver cirrhosis and hepatocellular carcinoma. The entire spectrum need not be experienced.
Table 4
Etiology/Riske factors
|
Book Picture
|
Patient Picture
|
|
Hepatitis
|
Nonalcoholic liver disease
|
|
Epstein Borr Virus (EBY)
|
|
|
Alcoholic liver Disease
|
|
|
Non Alcoholic liver disease
|
|
|
Auto immune hepatitis
|
|
Table 5
Clinical manifestation
|
Book Picture
|
Patient Picture
|
|
Nail Clubbing
|
Anemia
|
|
Anemia
|
Drowsiness
|
|
Drowsiness
|
Ascites
|
|
Ascites
|
Pallor
|
|
Hyperventilation
|
|
|
Jaundice
|
|
|
Bruising
|
|
|
Testicular atrophy
|
|
Table 6
Diagnostic evaluation
|
Book Picture
|
Patient Picture
|
|
History Collection
|
History Collection
|
|
Physical examination
|
Physical examination
|
|
LFT’s
|
LFT
|
|
Ultrasound
|
|
|
Biopsy
|
|
Management
The treatment of chronic liver Disease depend on the cause specific condition may be treated with medications including:-
Corticosteroids
Interferon
Antiviral
Supportive therapy for complication of cirrhosis included diuretics, albumin, Vitamin K, Blood products, antibiotics Nutritional therapy.
Other patients may require surgery or a transplant.
Assessment
Subject Data: After introduction, the patient as well as her daughter in law agreed to explain the problem. The patient was complaining of pain in Abdomen radiating towards back with fever and 3-4 episode of looses tools.
Objection Data: On assessing the patient, she seemed in pain and distress with altered sensorium. The patient was taking irrelevantly as had yellow discoloration. The patient layed flator the bed and showed of fatigue as weakness.
On examining the patient had ascites with aslerixis and Hepatomegaly and splenomegaly.
-
Vital Sings
PR------110bPm
SPO₂------98%
BP--------102/56 mmHg
RR-------18/min
Table 7
Nursing core plan
|
Nursing Diagnosis
|
Goal/objective
|
Interventions
|
Evaluation
|
|
Disturbed fluid volume related to decreased plasma protein as evidenced by edema
|
To achive normal electrolyte levels as no edema
|
Monitored serum Albumin and electrolyte levels. Administered medications as ordered. Monitored patients input/output
|
Edema was reduced.
|
|
Impaired Skin integrity related to altered metabolic state as evidenced by poor skin turgor, edema and ascites
|
Maintain the skin free from breakdown
|
Assisted the patient in repositioning. Elerated lower extremities to facilitate reduction of edema by placing a pillow under her legs. Inspected the patients skin thoroughly, taking note of the pressure points.
|
Skin Integrity was maintained.
|
|
Altered mental status related to inability of liver to detoxify toxins as evidenced by confusion, irrelevant taking and altered sensonium
|
To maintain usual level of reality orientation
|
Observed the signs and symptoms of behavioral change: Lethargy, confusion, drowsiness, shivering of speech and irritability. I reviewed current medication regime for any adverse reaction. I learned about patient sleep schedule.
|
The patient was reoriented to the reality with lime.
|
|
Ineffective breathing pattern related to the accumulation of intra abdominal fluid as evidenced by increased abdominal girth, presence of edema
|
To maintain and effective respiratory pattern and vital sings within acceptable limits.
|
Monitored respiration rate, depth and effort taken by the patient. I maintained the head of bed elevated at 30 Degree. Monitored ABG,s and vital signs as O2 saturation. Administered diuretics to get rid of the excess fluid.
|
Effective respiratory pattern was achieved to certain extend.
|
Table 8
Diet chart
|
Name of the Drug
|
Pharmacological Action
|
Range
|
Route
|
Indication
|
Contraindication
|
State effect
|
Nurses Responsibility
|
|
Carca (Carvedild)
|
It slows down the heart and lowers the blood pressure
|
3.125 mg BD
|
Oral
|
Hypertension Angina Heart failure
|
Serere brady Cordial serer Hypotension hypersensitivity
|
Decreased B.P Headache fatigue Dizziness
|
Should be taken with food. Make Sure patient doesn’t stop care suddenly, it should be tapered down
|
|
Rifoximin Rif gut)
|
It lowers the levels of ammonia producing bacteria in blood
|
550mg BD
|
Oral
|
Hepatic encephalopathy
|
Hypersentivity
|
Dizziness Nausea edema Asaites fatigue
|
It should be discontinued if the patient has server Dtorrbe
|
|
Aldactone
|
Lower B.P by re Moring Excess salt as H₂o without loss of K
|
5 mg OD
|
Oral
|
Hypertension edema Hypokalemia
|
Hyperkalemia Hyponatxmia Aaite Kidney failure
|
Nausea Vomiting leg ramps Dizziness
|
Should be taken with food. Unsafe to use during pregnant
|
|
Vitom K
|
Corrects PT in patient with Cirrhosis to correct co agulopathy
|
10mg
|
IM
|
Hepatic failure VK deficiency Cystic fibrosis
|
Renal impairment Hypersensitivity
|
Diarrhea
|
Cheek for hypersensitivity
|
Progress Note
The patient mental status was returned to normal
The patient was able to maintain a normal and effective breathing.
The client’s pain got significantly reduced.
The client was relived of pain as appeared to be more relaxed in a couple of days.
The patient’s anxiety got reduced.
The patient displayed appropriate range of fallings and lessened fear.
Health Teaching
I advised the patient to avoid all substance that can further damage the liver.
I advised that the patient should lower the consumption of salt in the diet.
I advised the patient to keep up with the medications and return to the follow ups.
I advised the patient to take healthy foods and supplements.
I advised the patient and his family members about getting vaccines for virus that can further damage the liver.
Advice on discharge
The patient was advised to take:-
Tab CARCA 3.125mg BD
Tab Rifgut 550mg BD
Tab Aldactone 50mg OD
Tab Trombopag 50mg OD for 1 week, repeat CBC
Low Salt Diet
Syp 100Z 15mL BT
Moreover, the patient was advised to repeat CBC in week, follow up in OPD 137/138, to be related for TACE once platelet count is more than 60k.
Summary
A 70-year-old female admitted in hospital with CLD with encephalopathy. The patient has been gastro enterology since 8 days during which complete care was provided. A proper medication was given and was observed for complications.
Conflict of Interest
None.
Article DOI
