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I. Introduction Patient's Profile History of Present Illness Mr.

A 35 years old man and a resident of Washington Legazpi city is admitted to Bicol regional training and teaching hospital because of pain in the abdomen and weakness during the assessment it was noticed that the patient has yellowish skin and sclera the initial diagnosis of the patient is

a. Present History b. Developmental History during the assessment the patient said that he was then a heavy alcohol drinker before the onset of the disease the patient said that he drink at least 3x a week, this factor may be contribute to the progression of the disease. c. Medical History 3 years ago the patient is diagnosed with hepatitis B, the patient also diagnosed having cholelithiasis and undergo cholecystectomy. d. Social History II. Anatomy and Physiology The liver is a vital organ present in vertebrates and some other animals. It has a wide range of functions, including detoxification, protein synthesis, and production of biochemical necessary for digestion. The liver is necessary for survival; there is currently no way to compensate for the absence of liver function long term, although liver dialysis can be used short term. This organ plays a major role in metabolism and has a number of functions in the body, including glycogen storage, decomposition of red blood cells, plasma protein synthesis, hormone production, and detoxification. It lies below the diaphragm in the abdominalpelvic region of the abdomen. It produces bile, an alkaline compound which aids in digestion via the emulsification of lipids. The liver's highly specialized tissues regulate a wide variety of high-volume biochemical reactions, including the synthesis and breakdown of small and complex molecules, many of which are necessary for normal vital functions The liver is a reddish brown organ with four lobes of unequal size and shape. A human liver normally weighs 1.441.66 kg (3.23.7 lb) and is a soft, pinkish-brown, triangular organ. It is both the largest internal organ (the skin being the largest organ overall) and the largest gland in the human body. It is located in the right upper quadrant of the abdominal cavity, resting just below the diaphragm. The liver lies to the right of the stomach and overlies the gallbladder. It is connected to two large blood vessels, one called the hepatic artery and one called the portal vein. The hepatic artery carries blood from the aorta, whereas the portal vein carries blood containing digested nutrients from the entire gastrointestinal tract and also from the spleen and pancreas. These blood vessels subdivide into capillaries, which then lead to a lobule. Each lobule is made up of millions of hepatic cells which are the basic metabolic cells.

III.Pathophysiology In patients with chronic diseases of the liver, fibrosis (scarring) of the liver often occurs. When the scarring becomes advanced, the condition is called cirrhosis of the liver. Ascites is excessive fluid that accumulates in the abdominal (peritoneal) cavity. It is a complication of cirrhosis and appears as an abdominal bulge. The peritoneum is the inner lining of the abdominal cavity, which also folds over to cover the organs inside the abdomen such as the liver, gallbladder, spleen, pancreas, and intestines. Ascites develops because of a combination of two factors: 1. increased pressure in the vein system that carries blood from the stomach, intestines, and spleen to the liver (portal hypertension); and 2. a low level of the protein albumin in the blood (hypoalbuminemia). Albumin, which is the predominant protein in the blood and which helps maintain blood volume, is reduced in cirrhosis primarily because the damaged liver is not able to produce enough of it. Other consequences of portal hypertension include dilated veins in the esophagus (varices), prominent veins on the abdomen, and an enlarged spleen. Each of these conditions is due primarily to the increased pressure and accumulation of blood and excess fluid in the abdominal blood vessels. The fluid of ascites can be removed from the abdominal cavity by using a syringe and a long needle, a procedure called paracentesis. Analysis of the fluid can help differentiate ascites that is caused by cirrhosis from other causes of ascites, such as cancer, tuberculosis, congestive heart failure, and nephrosis. Sometimes, when ascites does not respond to treatment with diuretics, paracentesis can be used to remove large amounts of the ascitic fluid. Peripheral edema, which is usually seen as pitting edema of the legs and feet, also occurs in cirrhosis. The edema is a consequence of the hypoalbuminemia and the kidneys retaining salt and water. The presence or absence of edema in patients with cirrhosis and ascites is an important consideration in the treatment of the ascites. In patients with ascites without edema, diuretics must be given with extra caution. Diuresis (induced increased volume of urine by use of diuretics) that is too aggressive or rapid in these patients can lead to a low blood volume (hypovolemia), which can cause kidney and liver failure. In contrast, when patients who have both edema and ascites undergo diuresis, the edema fluid in the interstitial space serves as somewhat of a buffer against the development of low blood volume. The excess interstitial fluid moves into the blood vessel spaces to rapidly replenish the depleted blood volume.

IV. Diagnostic Evaluation/ Lab Exams Diagnostic procedure: Liver function tests are a battery of tests that give your doctor an idea of how well your liver is working. From these studies, your doctor can identify possible liver disease, medication stress on liver function, or infections of the liver such as hepatitis. There are several different tests that comprise LFT's Total Bilirubin (TBIL) Bilirubin is a normal component of red blood cells. When these cells break down free bilirubin is released in the blood. Bilirubin is then carried to the liver where it is broken

down and excreted. When the liver is not functioning properly, bilirubin builds up in the body, causing jaundice (yellowing of the skin and eyes and darkening of the urine). Normal values: less than 1.0 Elevated: usually caused by a dysfunction of the system that breaks down bilirubin which includes the liver. Such an elevation can be caused by an obstruction or liver failure. Albumin (ALB) Albumin is a protein produced by the liver that helps maintain osmotic pressure in the vascular space. By maintaining this pressure, fluid stays in the vascular system instead of leaking out into the tissues resulting in swelling (edema). Albumin also carries certain minerals in the blood stream. Normal values: 4 - 6 Elevated: Usually indicates dehydration Below normal: Can indicate liver dysfunction or insufficient protein intake.

Laboratory exam result: Bilirubin: Creatinine :

V. Medical Treatment and Evaluation Treatment Apart from removing the cause, cirrhosis of the liver cannot be treated. The emphasis is therefore on dealing with and reducing the complications of the disease. The following approaches are used:
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water tablets (diuretics) for the treatment of fluid retention in the legs (oedema) or abdomen (ascites). vitamins and mineral supplements. calorie supplements (usually sugar-based drinks) to maintain nutrition. laxatives (usually a syrupy solution called lactulose) to prevent constipation and to reduce the chances of the poisonous substances from the bowel bypassing the liver and reaching the brain, causing drowsiness, confusion and coma (hepatic encephalopathy). some patients who have had bleeding from ruptured varicose veins in the lower oesophagus may be put onto a drug called propranolol, which reduces the pressure in those veins and lowers the chances of them bleeding again. finally, liver transplantation may be considered in patients with end-stage cirrhosis.

Treatment of fluid volume excess related to liver cirrhosis

Edema and ascites. Retention of salt and water can lead to swelling of the ankles and legs (edema) or abdomen (ascites) in patients with cirrhosis. Doctors often advise patients with cirrhosis to restrict dietary salt (sodium) and fluid to decrease edema and ascites. The amount of salt in the diet usually is restricted to 2 grams per day and fluid to 1.2 liters per day. In most patients with cirrhosis, however, salt and fluid restriction is not enough, and diuretics have to be added. Diuretics are medications that work in the kidneys to promote the elimination of salt and water into the urine. A combination of the diuretics spironolactone (Aldactone) and furosemide can reduce or eliminate the edema and ascites in most patients. During treatment with diuretics, it is important to monitor the function of the kidneys by measuring blood levels of blood urea nitrogen (BUN) and creatinine to determine if too much diuretic is being used. Too much diuretic can lead to kidney dysfunction that is reflected in elevations of the BUN and creatinine levels in the blood. Sometimes, when the diuretics do not work (in which case the ascites is said to be refractory), a long needle or catheter is used to draw out the ascitic fluid directly from the abdomen, a procedure called abdominal paracentesis. It is common to withdraw large amounts (liters) of fluid from the abdomen when the ascites is causing painful abdominal distension and/or difficulty breathing because it limits the movements of the diaphragms. Another treatment for refractory ascites is a procedure called transjugular intravenous portosystemic shunting (TIPS, see below).

VI. Drug Study VII. Nursing Care Management a. Ongoing Assessment b. Diet Diet is crucial with patient having liver cirrhosis, the liver cannot metabolize nutrients intake it is important to have adequate nutrient through proper diet, helpful diet like fruits, vegetables whole grains and proteins of proper types and in proper amounts are very appropriate. It is also needed to limit the sodium intake to prevent fluid retention leading to fluid volume excess which is characterized by edema and ascites. Protein intake in right amount is important because the liver cannot handle large amount of protein when the body have high amount of protein it can lead to another complication which is encephalopathy. This happens when large amount of protein accumulate and having a byproduct of ammonia which is toxic to the brain. c. Sex Untreated liver failure is associated with both loss of libido and impotence. Once a liver begins to fail, as when a man begins to age, he will start to show signs of feminisation as the balance between his oestrogen and testosterone is changed. This change results in the redistribution of fat and loss of muscular strength and a reduction in virility. A masculine figure loses strong limbs and muscular chest and the abdomen becomes paunchy as breasts enlarge. Testes and genitalia shrivel and the patient becomes less able to sustain erections.

Important as penetrative sex may be, successful sexual congress is far more closely related to the emotional bond between people than the physical strength of a transitory erection. It may well be that our reader is dwelling on her dying husbands potency as this is a marker for all the grief she feels for his potential loss. She should reassess her values. d. Possible Complication There are three common complication of liver cirrhosis the most common is (1)fluid volume excess which is manifested by edema and ascites the second one is (2)hypoglycemia in the case of cirrhosis -- the liver isn't able to store enough energy (in the form of glycogen, a chemical the body uses for quick energy) the last one is (3)encephalopathy is the occurrence of confusion, altered level of consciousness and coma as a result of liver failure. In the advanced stages it is called hepatic coma or coma hepaticum. It may ultimately lead to death VIII. NCP Discharge Plan a. Meds b. Exercise c. Treatment d. Health Education

e. Observe Signs of Complications Observe for any signs of complication like decrease level of consciousness that may be a sign of encephalopathy, general malaise and weakness that maybe a sign of hypoglycemia lastly observe for any edema and weight gain that maybe related to fluid volume excess. Esophageal varices, which are swollen veins in the esophagus due to portal hypertension. These bulging veins can burst, leading to life-threatening hemorrhage. f. Diet IX. Implications to: a. Nursing Service b. Nursing Educations c. Nursing Research X. References http://www.medicinenet.com/edema/page4.htm http://www.netdoctor.co.uk/diseases/facts/cirrhosisliver.htm http://www.nlm.nih.gov/medlineplus/liverdiseases.html http://www.nlm.nih.gov/medlineplus/ency/article/000255.htm