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Philippine Christian University Mary Johnston College of Nursing 415 Morga St.

Tondo, Manila


Prepared by: RLE GROUP III-sub group I

Antiquando, Bernalie N. Gabriel, JonaMae L. Saldua, Abigail S.

Submitted to: Ms. Nicoleta M. Dizon Clinical Instructor Medicine Ward

Date: July 26, 2010


We would like to acknowledge the contributions of the following individuals to the development of this case study. Ms. Dizon, for continually guiding and supporting us throughout our duty at the Medicine ward, for helping us in enhancing and improving our skills in the area. For the patience that she shows us despite of our attitude and mistakes. To the school librarian, Ms. Vicarme, for directing and helping us to utilize the library stacks for us to have our research. To the staff nurses/nurses on duty at the Medicine Ward of Mary Johnston Hospital for the support and providing us with enough information in the routines in the area which we were able to apply. For our parents/families that provided us enough guidance, moral and financial support and other resources to be able to finish this case study. To our fellow group mates for their continuous support and sharing their knowledge for polishing this case study. To the patient, as well as his family members, for being cooperative and compliance to our nursing care and health teaching, that enable as to dig deeper in knowing and studying the patients case. Above all, we want to give our deepest gratitude to the Lord God Almighty, who gave us the opportunity to be with one of our patient and have the experience of sharing every bit of quality nursing care with him and for sustaining us in doing this case study.

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Liver, largest internal organ of the human body. The liver, which is part of the digestive system, performs more than 500 different functions, all of which are essential to life. Its essential functions include helping the body to digest fats, storing reserves of nutrients, filtering poisons and wastes from the blood, synthesizing a variety of proteins, and regulating the levels of many chemicals found in the bloodstream. The liver is unique among the bodys vital organs in that it can regenerate, or grow back, cells that have been destroyed by some short-term injury or disease. But if the liver is damaged repeatedly over a long period of time, it may undergo irreversible changes that permanently interfere with function. A healthy liver is able to regenerate most of its own cells when they become damaged. With end-stage cirrhosis, the liver can no longer effectively replace damaged cells. A healthy liver is necessary for survival. Cirrhosis is a condition in which the liver slowly deteriorates and malfunctions due to chronic injury. Scar tissue replaces healthy liver tissue, partially blocking the flow of blood through the liver. Scarring also impairs the livers ability to control infections, remove bacteria and toxins from the blood, process nutrients, hormones, and drugs, make proteins that regulate blood clotting, produce bile to help absorb fatsincluding cholesteroland fat-soluble vitamins As the liver's capacity to function is compromised, a variety of complications develop throughout the body. Jaundice results from the livers inability to process bilirubin, a pigment that forms as a result of the breakdown of old red blood cells. The buildup of this pigment causes the yellow discoloration of the skin and eyes characteristic of jaundice. Decreased production of a blood protein known as albumin, along with hormonal and kidney abnormalities, leads to retention of fluid, especially in the abdomen. Decreased production of clotting factors by the liver makes cirrhosis patients bruise and bleed easily. Inefficiency in breaking down toxins in the blood can cause neurological symptoms, including confusion, sleeplessness, and even coma.

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Cirrhosis is considered as the twelfth leading cause of death by disease, accounting for 27,000 deaths each year. The condition affects men slightly more often than women. This is a case of a 62y/o patient, diagnosed with Liver Cirrhosis, with chief complaints of difficulty of breathing and enlargement of the abdomen and was admitted at Mary Johnston Hospital. Within the 3 days of duty and nursing care to him, the following nursing problems/diagnosis was identified: High Risk For Injury: Bleeding alteration in comfort: visceral pain Activity Intolerance Altered peripheral tissue perfusion related

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GENERAL OBJECTIVE At the end of this case study, the student nurse will be able to explore and conduct a thorough study about the facts and other related information about liver cirrhosis. SPECIFIC OBJECTIVE At the end of the case study, the student nurses will be able to: Gather significant information from the client including the Gordons Functional Health Pattern and Physical Examination that justifies his disease condition. Gather and study about the signs and symptoms of the client to the manifestation of typhoid. Evaluate and interpret the diagnostic tests of the disease. Identify the actions, doses and nursing considerations of the medications given to the client. Make appropriate nursing care plans with effective and interventions.

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We chose Mr. R.S.Bs condition for our case study, first of all because we find his case as a rare one and we were fortunate for having the opportunity to handle such kind of patient with liver cirrhosis. We were also able to handle him for 3 consecutive days which enabled us to monitor him and apply appropriate nursing care related to his ailment. We find his disease condition as an interesting one because the actual signs and symptoms are visible. We find it curious how does those clinical signs and symptoms appeared and what could we do as student nurses, to alleviate the discomforts that he feels and for the possible complications that would arise.

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Name: Mr. R.S.B Gender: male Age: 62 years old Date of Birth: December 28, 1977 Address: Blk 15 Lot P2A3 Kaunlaran St. , Caloocan City Citizenship: Filipino Religion: Baptist (Christian) Occupation: retired seaman

Date of Admission: July 10, 2010 Chief Complaint: Difficulty of breathing, enlarged abdomen Companion: Fe Bequilla

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History of Present Illness -signs and symptoms started during his work in year 1998-1999 -patient didnt pay attention to signs and symptoms and still keep working -onset of the symptom is gradual those are radiating pain in the abdominal area and difficulty of breathing -Problem occurs during heavy lifting in work, eating large quantity of foods and increase activity -stabbing pain in abdominal area from LUQ to RLQ and RUQ to LLQ

Past History -chickenpox, mumps and measles already occurred in patient -admitted on different hospitals for the chief complaint of DOB and enlarging abdomen -the client take robitussin syrup for his cough and DOB -DM type 2 was diagnosed 6 years ago at the age of 56 in year 2004

Family History Mothers side: Hypertension, Asthma Fathers side: Hypertension

Lifestyle Personal Habits: 20 years smoking start around 1980s as stated by the client Consumed 1-2 packs of cigarettes per day Smoking ceases in the year 2000 Consumed one case of alcoholic drink per occasion magdamagan ako umiinom nun, di ko na mabilang yung bote as stated by the client

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Drinking alcoholic drink ceases in year 2001

Diet: Retired chef on the ship Eating food he desired specially chocolates During hospital confinement he was under soft low fat low sodium diet

Social Data -member of Senior Citizen Association of the Philippines -member of Tanglao Baptist Church -high school graduate -retired chef on the ship -delicious and fatty foods exposed to him as a chef -client is under RX senior -pension and his children were the one spending for his hospitalization

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HEALTH MAINTENANCE / MANAGEMENT -maganda, kapag malusog as stated by the client -taking Vitamin K once a day -tooth brushing 2-3x a day -taking a bath everyday

METABOLIC PATTERN -kanin ,ulam ,isda, sabaw as stated by the client -wala pang isang tasang kanin as stated by the client -mahilig yan sa chocolates chef kasi sa barko yan, kaso nagkadiabetes as stated by his wife -mga 200ml, sukat niya ngayon sa inom ng tubig as stated by his son -medyo malakas uminom nakakawalong baso naman dati yan as his wife stated

ELIMINATION PATTERN -oo, mahirap dumumi, sumasakit tyan ko as stated by the client -medyo yellowish, medyo matigas yung iba malambot as stated by his daughter -dati lagi namn ako naihi ng maayos, pero ngayon naksonda na ako as stated by the client -mag-iisang lingo na akong naksonda as patient stated -soft yellowish stool in 1st and 2nd day -brown and soft stool in small pieces with water as seen in 3rd day handled -bright yellow to tea colored uring draining in FC-CDU -dati yellowish to orange kulay ng ihi as stated by the client - wala naman masakit pag umiihi ako noon, medyo marami din as stated by the client

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SLEEP AND REST -di tuloy tuloy may mga nurse na dumadalaw eh as stated by the client -naiidlip naman ako sa araw, basta ayoko ng maingay as stated by the client -malalim naman, medyo nagigising lang as stated by the client - eight hours or more than before he was admitted - 2-3 hours of continuous sleep at night - 30 minutes to one hour nap time at day - usually in supine position with hands on abdomen or in chest - with 1-2 pillows on head when sleeping - in semi-fowlers position sleeping in the hospital bed

ACTIVITY AND EXERCISE -dati nag-eexercise ako, isang sit-up tapos may barbell pa as stated by the client -wala naman sa ngayon, nakahiga sa bahay nagpapahinga as stated by the client -nakikinig sa radyo tapos nagpapahinga, nagbabasa ng dyaryo as stated by his wife

COGNITIVE PERCEPTUAL -not wearing glasses and hearing aids -oo, naririnig kita ng maayos as responded by the client when talking in 2 ft. distance -aware of time, date, day and place where he is

ROLES AND RELATIONSHIPS -misis ko kasam ko sa bahay as stated by the client

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-siya yung panganay kung anak (pointed at maam Raquel) as said and done by client -mga pamangkin din kasama naming sa bahay as stated by the client -wala naman kaming problema na pinag-aawayan, minsan lang kami mag-away as stated by the client -visit and watch over by his wife, daughter, niece and nephews in the hospital -member of Senior Citizen Association of the Philippines -active member of Tanglao Baptist church -visited by their Pastor and co-church members and pray for him

SELF-PERCEPTION -mahina na ako, mahirap maglakad medyo sakitin na rin as stated by the client -pasensya na kayo kung putol-putol yung salita ko kasi nahihirapan ako huminga, pasensya na as stated by the client

SEXUALITY/REPRODUCTIVE -with two daughters and one son - uses condom as method of family planning -no sexual drive in current health status

COPING STRESS -pag may problema, pumupunta ako sa senior citizen club namin, 700 ang mga kaibigan ko dun at mga tauhan ko dun as stated by the client -sa ngayon wala na akong problema as stated by the client -yung kalusugan saka sakit na lang niya ngayon, yung pabalik balik ng ospital yung problema namin as stated by his wife

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VALUES AND BELIEFS -sa baptism church, Christian ako as stated by the client -linggo-linggo nagsisimba ako, ngayon lang hindi kasi may sakit ako as stated by client -sa Tanglao Baptist Church ako nagsisimba as stated by the client -no superstitious beliefs followed - visited by their Pastor and co-church members and pray for him -his wife always reading bible verses for him

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General Appearance: -seen lying in bed in semi-fowlers position -wearing green hospital gown -with FC-CDU draining tea colored urine in 200cc amount -with #2 D5NM 1L x 16 hours infusing well at right metacarpal vein -with jaundice

Skin: -poor skin turgor (3-4secs) -dry skin as noted -presence of cherry angiomas on the neck -with senile lentigines or melanotic freckles on hands and face -wrinkled skin in outer canthi of the eyes -with palmar pallor -crusting lesions on the lower leg -black discoloration on the right and left lower leg until the feet -edema +1 on both leg

Head: -with whitish, gray and some black hair - no pediculosis - no seborrhic dermatitis -dry scalp -dry hair -no lesions

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Face Eyes: -gray to white color of eyebrows -thick eyebrows -with long black eyelashes -black color of both eyes -pupil equally round and reactive to light accommodation -teary and moist eyes -with crusting in the eyes -with icteric sclerae in both eyes -visible red small vessels on sclera of the eyes -pale conjunctiva Nose: -pointed nose -nasal flaring noted -presence of small amount of cilia -slight redness on top of the nose Ears: -ears were aligned on the outer canthus of the eyes -presence of hardened yellowish earwax -can hear clearly in a distance of feet or more -no inflammation seen

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Mouth: -pale lips -crack and dry lips -presence of thick salivation -with small yellowish teeth -missing teeth on both upper and lower case -not wearing dentures -with mouth sore on the left check -pale gingival -with slight bad mouth odor -can open mouth in small size - speak clearly -weak voice Neck: -supple neck - can move according to ROM -presence of Adams apple -no palpable mass or inflamed lymph node

Chest: -with rhythmic breathing pattern -no retractions noted -audible heart sounds -audible wheezing sounds of the lungs -flat and in symmetry -symmetric brown areola and nipples

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Abdomen: -enlarged globular abdomen -measured 104 cm. in size -borborygmi sound heard as auscultated -tenderness was palpated -3 out of 10 in pain scale when palpated -dirty umblilicus

Upper Extremities -can move according to range of motion -presence of melanotic freckles on arms and hands -capillary refill of 3 seconds -visible vascularity in the lower arm part -long and yellowish nails

Lower Extremities -move with limited and slow range of motion -can do flexion and extension -needs assistance when walking -with black pigmentation on both lower legs to feet -dry skin noted -nails were yellowish, dried and slightly cracked -capillary refill of >3 seconds - edematous as note with degree of +1

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FUROSEMIDE Drug class: Loop Diuretic Action: Inhibits reabsorption of sodium and chloride from the proximal and distal tubules and ascending limb of the loop of Henle, leading to a sodium-rich dieresis. Indications: Edema associated with heart failure, cirrhosis, renal disease; hypertension Contraindication: Allergy to furosemide; anuria, severe renal failure Adverse effects: paresthesia, orthostatic hypotension, cardiac arrhythmias Nursing Considerations: Assess for history of allergy; severe renal failure Assess for pulses, BP, orthostatic hypotension, renal function tests, uric acid, and weight ! Administer with food or milk to prevent GI upset ! Give early in the day so that increased urination will not disturb sleep !Weight patient daily

This drug is given to the patient because of the presence of edema, which is a late symptom of liver cirrhosis. It acts as a loop diuretic that promotes excretion of fluid through the kidneys. It is the nurses responsibility to encourage the patient to have adequate intake of potassium and calcium for the maintenance of normal fluid and electrolyte balance. Monitor intake and output and weigh the patient daily is part of the nursing assessment.

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METRONIDAZOLE Drug class: Amebicide, antibacterial, antibiotic, antiprotozoal Action: Bactericidal: Inhibits DNA synthesis in specific anaerobes, causing cell death; antiprotozoal-trichomonacidall, amebicidal: Biochemical mechanism of action is not known. Indication: Acute infection with susceptible anaerobic bacteria ; Amebic liver abscess Contraindication: Hypersensitivity to metronidazole Adverse effects: insomnia, vomiting, diarrhea, GI upset, darkening of the urine Nursing Consideration: Assess for history of hepatic disease; Assess for abdominal examination, liver palpation, urinalysis ! Administer oral doses with food ! Expect darker color of urine

Since the patient has liver cirrhosis, he has great risk of developing bacterial peritonitis because of the absence of intra-abdominal source of infection and impaired production of immunoglobulin. This drug is given to prevent further infection by inhibiting the microorganisms involve.

CILOSTAZOL Drug class: Antiplatelet Action: Reversibly inhibits platelet aggregation induced by a variety of stimuli including ADP, thrombin, collagen, shear stress, epinephrine, and arachidonic acid by inhibiting cAMP phosphodiesterase III; produces vascular dilation in vascular beds with a specificity for femoral beds; seems to have no effect on renal arteries. Indication: Reaction symptoms of intermittent claudication allowing increased walking distance; Management of peripheral vascular disease Contraindication: Allergy too cilostazol, active bleeding, hemostatic disorder

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Adverse effect: Tachycardia, palpitations, diarrhea Nursing Considerations: Assess for history of allergy, heart failure Assess for normal output, BP !Administer drug on empty stomach atleast 20 minutes before or 2 hours after breakfast or dinner

This drug is given to prevent formation of varices or hemorrhoids on his esophagus. In patients with liver cirrhosis, there is obstruction to blood flow through the liver caused by fibrotic changes which also results in the formation of collateral blood vessels in the esophagus and other sites like stomach/GI system.

PROPANOLOL Drug class: Antianginal, antiarrythmic, antihypertensive, Beta-adrenergic blocker Action: Competitively blocks beta-adrenegic receptors in the heart and juxtoglomerular apparatus, decresing the influence of the sympathetic nervous system on these tissues, the excitability of the heart, cadiac workload and oxygen consumption, and the release of rennin and lowering BP; has membrane-stabilizing effects that contribute to its antiarrhythmic action; acts in the CNS to reduce sympathetic outflow and vasoconstrictor tone. Indication: Hypertension; Cardiac arrhythmias, Angina pectoris caused by coronary atherosclerosis Contraindication: Allergy to beta-blocking agents, sinus bradycardia, bronchospasm Adverse effects: Respiratory distress, Bradycardia, cardiac arrhythmias, dyspnea, Nursing Considerations: Assess for allergy to beta-blocking agents, sinus bradycardia bronchospasm, Assess for BP, RR, PR ! Take drug with meals

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! Do not discontinue drug abruptly after long-term therapy; to avoid worsening of your condition

Beta-blockers can lower the pressure in the varices and reduce the risk of bleeding.

SPIRONOLACTONE Drug class: Aldosterone antagonist, Potassium sparing diuretic Action: Competitively blocks the effects of aldosterone in the renal tubule, causing loss of sodium and water and retention of potassium. Indication: Adjunctive therapy in edema associated with heart failure, nephrotic syndrome, hepatic cirrhosis, hypertension, hypokalemia Contraindication: Allergy to spironolactone, hyperkalemia, renal disease, anuria Adverse effects: diarrhea, hyperkalemia, Nursing considerations: Assess for allergy; hyperkalemia; renal disease Assess for BP edema ! Give daily doses early so that increase urination does not interfere sleep ! Measure and record regular weight to monitor mobilization of edema fluid ! Avoid giving food rich in potassium

Potassium-sparing diuretics is indicated to our patient to decrease the ascites present, and to minimize the fluid and electrolyte changes.

DOPAMINE HYDROCHLORIDE Drug class: Alpha-adrenergic agonist, Beta1selective adrenergic agonist, Dopaminergic drug, Sympathomimetic

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Action: Drug acts directly and by the release of norepinephrine from sympathetic nerve terminals; dopaminergic receptors mediate dilation of vessels in the renal and splanchnic beds, which maintains renal perfusion and function; alpha receptors, which are activated by higher doses of dopamine, mediate vasoconstriction, which can override the vasodilating effects; beta1 receptors mediate a postitive inotropic effect of the heart. Indications: Correction of hemodynamic imbalances , poor perfusion of vital organs, hypotension Contraindications: tachyarrhythmias, ventricular fibrillation, hypovolemia, Adverse effects: tachycardia, palpitations, hypotension, vasoconstriction, Nursing considerations: Assess for history of tachyarrythmias, hypovolemia, Assess for BP, pulse pressure ! Exercise extreme caution in calculating and preparing doses; dopamine is a very potent drug

CIPROFLOXACIN Drug class: Antibacterial, Fluoroquinolone Action: Bactericidal: interferes with DNA replication in susceptible bacteria preventing cell reproduction Indications: infections caused by susceptible gram-negative bacteria, UTI, LRTI Contraindicated: Allergy to fluoroquinolones Adverse effects: Arrythmias, hypotension, renal failure, Nursing considerations: Assess for allergy, renal impairment !Drink plenty of fluids when taking this drug.

This drug is given with metronidazole, also an anti bacterial agent, for synergistic effect. To prevent the reproduction of bacteria that causes peritonitis.

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VITAMIN K (Phytonadione, AquaMEPHYTON) Action: Vitamin K is used to prevent and treat hemorrhagic diseases. It is a necessary component for the production of certain coagulation factors (II, VIII, IX and X) and is produced by microorganisms in the intestinal tract. Indication: bleeding disorders, hepatic disfunction Adverse effects: Local irritation, pain and swelling at the site of injection Nursing considerations: Assess for signs of bleeding, hematuria, hematochysia !Obtain first the prothrombin time before administration. ! Presence of signs of bleeding may indicate larger amount of vitamin K necessary

Decreased production of clotting factors is due to deficient absorption of vitamin K from the GI tract. This is cause by the inability of liver cells to use vitamin K to make prothrombin. Vitamin K injections is given to improve blood clotting factors.

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Laboratory Results

Result Creatinine Potassium Total Protein Albumin ALT ALKP Globulin 4.1 mmol/L 108 mmol/ L 77 g/L 25 g/L 58 u/L 304 u/L 52 u/L

Normal Value 3.6 5.0 mmol 62-133 mmol 63-82 g/L 35-50 g/L 9- 72 u/L 38-126 u/L

Evaluation Normal Normal Normal decrease Normal Increase

Interpretation: Enzyme tests are done to indicate liver cell damage.Most of the results are within normal range which indicates that the patient nutritional status is not completely altered. 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. The decrease in his albumin results from the dysfunction of the liver. While alkaline phosphatase is an enzyme found in many organs in the body, including the liver. Increase amount of it indicates liver dysfunctions resulting in tissue damage.

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Hematological Results Result Hemoglobin Hematocrit Leukocyte Segmentars Lymphocytes Monocytes Eosinophils Platelet count Prothrombin time Interpretation: Complete Blood Count was done to the client to determine blood components and the response to the inflammatory process regarding the clients disease condition. Hepatic failure is often accompanied by coagulation and renal failure. Hemoglobin and hematocrit is decreased because of the decreased ability of the kidney to produce erythropoietin since its function is impaired. There is also a decrease in iron since too much iron is lost due to excessive bowel movement. Inadequate iron can impair hemoglobin production. Another factor is, the RBCs are excreted in the urine or there is hematuria. Leukocyte count is within normal range. However, segmentars are high which may indicate that there is a presence of infection or bacteria. There is a decrease in prothrombin, since it is produced in the liver. Slow prothrombin time shows that there is alteration in the coagulation process, which makes the patient prone for bleeding tendencies. That is why vitamin K, a coagulant factor is administered. 122 0.36 7.2 0.67 0.31 0.01 0.01 198x10 g/L 19secs. Normal Value 130 180 0.42 0.98 5- 10 x 10 g/L 0.36- 0.66 0.22- 0.40 0.04 0.08 0.01- 0.04 150- 400x 10 g/L Evaluation Decreased Decreased Normal Increased Normal Decreased Normal Normal Slow

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Urinalysis Result Color- amber Specific gravity- 1.030 Reaction 6.0 WBC- 3.6 Epithelial cells- few Mucous threads- plenty Interpretation: Presence of RBC and protein in the urine indicates the dysfunction of the kidneys nephrons which is responsible for the filtration of water, breakdown product of protein and trace substances from blood. The amber color of urine results because of the presence of bile, when it is not filtrated. Character- slightly turbid Protein- 1.0 g/L Sugar- negative RBC- 10-15 Bacteria- few Others: amorphous materials- moderate

Fecal Examination Consistency- mucoid Parasite- no parasite Interpretation The mucoid consistency results from the presence of mucoprotein, a group of various complex conjugated proteins combined with amino acid units that occur in body fluids and tissues. The heme molecules are converted to bilirubin which is normally taken up by the liver and released into the small intestine as part of the bile. Since the liver is not functioning normally, bilirubin builds up in the circulation. It then enters the intestine and is converted by the bacteria into other pigments. Some of these pigments give feces their brown color. Color- brown Ova- no amoeba seen WBC- 0-2 hpf

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Nursing Care Plan #1 ASSESSMENT Subjective Masakit ang tiyan ko pag ginagalaw as stated by the patient Objective: DIAGNOSIS High Risk For Injury: Bleeding Related To Altered Clotting Mechanism PLANNING At the end of 8 hours duty/nursing interventions, the patient will be able to prevent occurrence of injury as evidence by absence of bleeding. INTERVENTIONS: 1. Provided safe environment (pad side rails, prevent falls) RATIONALE: Minimizes falls and injury if falls occur, to prevent formation of ecchymoses or hematoma. Blood pressure of 80/50 Prothrombin time of 19secs Body malaise Needs assistance when walking With ecteric sclera noted Skin turgor of 4 secs. Capillary refill of more than 2 seconds in lower extremities.

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2. Instructed relatives to move away all sharp objects or replace them with safer items; Arranged IV connections to safety phase. RATIONALE: Avoids cuts and bleeding. 3. Instructed and assisted to turn side to side every 2 hours. RATIONALE: To avoid pressure ulcers/ bed sores. 4. Observed stool for color, consistency, and amount. RATIONALE: Melena or blood in the stool permits to identify or detection of bleeding in the gastrointestinal tract. 5. Recorded vital signs every hour. RATIONALE: To monitor for hypovolemic or hemorrhagic shock. 6. Maintained small frequent feeding, limit oral fluid intake up to 1 liter, keep head of bed elevate to 30-45degrees. RATIONALE: Reduces risk of aspiration of gastric contents and minimizes risk of further trauma to esophagus and stomach by preventing vomiting. 7. Instructed the relatives to use soft toothbrush and avoid using of toothpicks. RATIONALE: Prevents trauma to oral mucosa while promoting good oral hygiene. 8. Administered vitamin K as prescribed. RATIONALE: To promote clotting by providing fat-soluble vitamins necessary for clotting. 9. Administered medications carefully; monitored for side effects. RATIONALE: Reduces risk of side effects secondary to damaged livers inability to detoxify or metabolize medications normally.


Goal met! All interventions were effectively done and the high risk for injury: bleeding was prevented.

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Nursing Care Plan #2


-masakit sa may tyan parang mahapdi as stated by the patient -sumasakit sa banding taas ng tyan kapag umuubo, sak kapag kumikilos as stated by patient OBJECTIVE -facial grimacing noted -rubbing of the abdomen -guarding behaviour noted -pain scale of 3 out of 10 when at rest -pain scale of 4 out of 10 when moving -with tenderness as palpated -decrease in appetite

DIAGNOSIS: Alteration in comfort: visceral pain r/t increase peritoneal pressure:ascites s/t liver cirrhosis

PLANNING: At the end of 8 hours duty/nursing interventions, the patient will be able to feel comfortable and refresh as evidenced by smiling, uninterrupted sleep and pain scale of 0-1 out of 10.

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1. Respond immediately to complaint of pain. RATIONALE: Prompt responses to complaints may result in decreased anxiety in patient. 2. Eliminated additional stressors or sources of discomfort (positioned comfortable). RATIONALE: Patient may experience decreased ability to tolerate painful stimuli if environment, factors are further stressing them. 3. Provided PM care (bed bath, oral care, changed linen and gown) RATIONALE: To provide soothing and relaxing effect, to promote comfortable feeling. 4. Provide back and leg massage RATIONALE: To provide comfort and for better blood circulation. 5. Taught on relaxation techniques (slow-rhythmic breathing technique); diverting activities like talking to her wife or guided imagery each inhaled breath RATIONALE: Skeletal muscle relaxation is believed to reduce pain by relaxing tense muscles that contribute to pain. The patient imagines healing energy flowing to the area of discomfort. With each slow exhaled breath, the patient could imagine muscle tension and discomfort being breathed out, carrying away pain and tension and leaving behind a relaxed and comfortable body.

6. Provided rest periods RATIONALE: to facilitate comfort, sleep, and relaxation


GOAL MET! the patient was able to verbalize feeling of comfort and absence of pain and was able to sleep at without interruptions.

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Nursing Care Plan#3

ASSESSMENT SUBJECTIVE Nanghihina ako, at nahihirapang tumayo as stated by the patient Tulungan mo kong umupo, di ko kaya as stated by the patient

OBJECTIVES: Moving lower extremities slowly and not in full Range of Motion With orthostatic hypotension Easy fatigability noted Ambulating with assistance Weakness as noted Doing ADL (eating, bathing, toothbrushing) with assistance Turns side to side with assistance Labored breathing as noted: RR of 32bpm when ambulating

DIAGNOSIS Activity Intolerance related to fatigue and body malaise secondary to inability of liver to metabolize protein, fats and glucose.

PLANNING At the end of 8 hours duty/ nursing interventions, the patient will be able to verbalize decrease in fatigue and weakness, reports increase ability to participate in activities.

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1. Provided and assisted in doing activities and hygiene. RATIONALE: To promote exercise and hygiene within patients level of tolerance 2. Provided and encouraged to have adequate rest especially when abdominal discomfort occurs. RATIONALE: To conserve energy, protect the liver and reduce cardiac workload. 3. Refrained from performing nonessential procedures. RATIONALE: To promote rest 4. Encouraged to eat small frequent feeding of diet high in carbohydrates with protein intake consistent with liver function. RATIONALE: Provides calories for energy and protein for healing. 5. Progressed activities gradually. RATIONALE: To prevent overexerting the heart and to promote doing of activities as tolerated. 6. Encouraged and assisted in active ROM exercises as tolerated. RATIONALE: To maintain muscle strength and joint range of motion;

EVALUATION Partially Goal met. The patient was able to verbalize decrease in fatigue and weakness. Still do activities with assistance especially during ambulating.

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Nursing Care Plan #4

ASSESSMENT SUBJECTIVE Nangangalay yung mga binti ko. As stated by the patient


Weak peripheral pulse (lower extremities) With edema as noted (+1 on hands, +2 on legs) With Numbness on lower extremities Cool and clammy extremities as noted Prolonged capillary refill of 3secs Bp of 90/60 80/50 (taken on arms and feet) Labored RR of 18-22 Pulse Rate of 60-68 Alert level of consciousness as noted Decrease hematocrit level CBG of 137mg/dL

DIAGNOSIS Altered peripheral tissue perfusion related to decrease blood circulation and decrease mobility.

PLANNING At the end of 8 hours duty/nursing interventions, the patient will be able to, have optimal peripheral tissue perfusion as evidence by strong peripheral pulses, and maintain LOC and absence of numbness on extremities.

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1. Elevated legs. RATIONALE: Helps in venous return and the return of interstitial fluid to blood vessels. 2. Provide foot, leg, hands and arm massage; 3. Turn side to side every 2 hours. RATIONALE: For effective blood circulation and venous return; promotes mobilization of edema. 4. Elevated head of bed to 30-45degrees. RATIONALE: To reduce abdominal pressure on the diaphragm and permits fuller thoracic excursion and lung expansion; to prevent difficulty(labored) breathing and adequate blood oxygenation. 5. Encouraged and assisted to ambulate and do stretching as tolerated. RATIONALE: Ambulation can help in effective circulation of blood and fluids. 6. Advised to restrict sodium intake. RATIONALE: Sodium attracts more water, it should be restricted to minimize the formation of edema.

EVALUATION Goal Met! The patient was able to have optimal peripheral tissue perfusion; maintained level of consciousness, absence of numbness and capillary refill of 2secs.

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HEALTH PERCEPTION AND MAINTENANCE Provided knowledge that being healthy doesnt only pertains to physical aspect of a person but as well as his mental and emotional well being. Advised to use soft-bristled toothbrush to prevent bleeding gums. Instructed patient to keep fingernails short and smooth to prevent skin excoriation and infection from scratching. NUTRITION AND METABOLIC Encouraged to take nutritious, high-protein diet, if tolerated, supplemented by vitamins of the B complex and others as indicated including vitamin A, C, K and folic acid. Instructed to eat small frequent meals (6per day) than three large meals, because of the abdominal pressure exerted by ascites. Instructed to limit fluid intake of 1Liter per day as ordered by the doctor. Instructed to avoid alcohol consumption and foods rich in Sodium.


Encouraged to defecate each time the urge is felt. Provided information that the tea colored urine is due to the present of bile related to his present condition.

ACTIVITY/EXERCISE Advised patient to minimize activity and prolong his rest periods to permit the liver to reestablish its functional ability. It also reduces the demands on the liver and increased the livers blood supply.

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Encouraged and assisted in turning side to side, which could help in preventing such problems as pneumonia and pressure ulcers and to promote mobilization of edema.

Encouraged to increase activity gradually within tolerable limit, after nutritional status improves and strength increases. Instructed to ask for assistance to get out of bed. Instructed and assisted family members to perform range of motion exercises to the patient every 4 hours; and elevate the edematous extremities. Instructed patients relatives to make sure that side rails are always up to prevent falls. Instructed to maintain elevation of head of bed at least 30 degrees to reduce abdominal pressure on the diaphragm and permits fuller thoracic excursion and lung expansion.

SELF PERCEPTION Provided information for assessing impact of changes in appearance, sexual function, and role on the patient and family Encouraged to verbalized reactions and feelings about the changes in his physical body. Encouraged and assisted patient in decision making about care.

ROLES AND RELATIONSHIP Encouraged verbalization of feelings to family members. Encouraged family members to always be the client, to provide support and care.

VALUES AND BELIEFS Encouraged to always pray and ask for strength and encouragement.

Encouraged to read the bible every start and end of the day.
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INTERPERSONAL ASPECTS OF NURSING THEORY By: Joyce Travelbee According to Travelbee, nursing is accomplished through human-to-human relationships that begin with the original encounter that progresses thorough a series of stages of emerging identities, developing feelings of empathy, and later on, sympathy until such time that the nurse and patient have attained rapport in the final stage. The establishment of a nurse-patient relationship and the experience that is rapport is the end of all nursing endeavor. Rapport is that which is experienced when nurse and patient has progressed through the four interlocking phases preceding rapport and the establishment of a nurse-patient relationship.

Before we started our duty in the clinical area, we were trained and taught on the importance of communication and building of rapport not only to the client, well or ill, but as well as with the family. Therapeutic communication was our vehicle through us, student nurses, and patient relationship were established. We provided positive approach, during our initial interaction with him, since the patient has body malaise and irritable because of his present condition. Proper communication through good listening and proper asking of questions are done so that we were able to identify one another with respect to his condition and for our ability to offer assistance. Rapport was easily built which helped us to gain his cooperation and compliance in providing nursing care to him, and to receive further information about his present condition.

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SELF-CARE DEFICIT THEORY OF NURSING By: Dorothea Orem The main focus of this theory is the enhancement of the clients ability for self-care. When individual is unable to meet his own self-care requisites, a self-care deficit occurs. A persons self-care deficits are the result of environmental situations. The appropriate system that exist within nursing practice is the partially compensatory system wherein the student nurse and the patient help each other to perform self-care measures. It is shown below: Partially Compensatory System The nurse is responsible in: Performing some self- care measures for the patient Compensating for self-care limitations of the patient Assisting the patient as required

For the patient to: Performs some self-care measures Regulates self-care agency Accepts care and assistance from nurse

When an individual is unable to meet his own self care requisites, a self care deficit occurs. It is in the duty and obligation of the professional nurse to recognize and identify these deficits in order to define a support modality or intervention.

This theory is applicable to our patient during the time of our 3 days nursing care to him, due to his present condition. As we observed him, hes been a bed ridden for 3 days due to muscle weakness and difficulty of breathing. Self care deficit occurs, because he wasnt able to meet his own self care requisites like eating, bathing, changing clothes, defecating etc. It is our duty and obligation to recognize those deficits in order for us to define a support modality and
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interventions. As assigned students nurses to him, it is our responsibility to provide total patient and holistic care to our patient. We performed self-care measures to him like providing bed bath; help him to compensate for self-care limitations through assisting during going to the bathroom to defecate; and assist him in his daily routine. It is clear in this model, the importance of emphasizing on education and supportive measures to our client. We provided health teachings like the importance of withdrawal from alcohol to prevent further liver damageand to increase intake of protein to compensate to the decrease albumin.

HELPING ART OF CLINICAL NURSING By Ernestine Wiedenbach Wiedenbach defined nursing based on her field of maternity nursing. According to her, there are four elements in the art of nursing: philosophy, purpose, practice, and art. She viewed clinical nursing as being directed toward meeting the patients perceived need for help. The following are the major concepts and sub-concepts of her philosophy. 1. Patient- need for help 2. Nurse- purpose, philosophy, practice and art. In order for nurses to fulfill the nurses helping role, they should be able to identify patients need for help through: 1. Observing behavior consistent or inconsistent with their comfort 2. Exploring the meaning of their behavior 3. Determining the cause of their discomfort or incapability 4. Determining whether they can resolve their problems or have a need-for-help In her theory, she believes in the four elements to clinical nursing. In her first element, which is nurses philosophy, it is described as the attitude and belief about life and how that affected reality of them. As female student nurses who are spiritually molded by our institution, we were able to apply nursing care with respect for his dignity and worth as a male patient. Secondly is the nurses purpose. We traditionally visit our patient, a day or hours prior to our
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duty, so that we could formulate proper and accurate nursing care plan to him. We set plans or goals on what do we want to accomplish to our patient through our nursing interventions. We planned the activities directed toward the overall good of our patient based on the formulated nursing diagnosis. Next are the practice and art. Practices are the observable nursing actions that are affected by beliefs and feelings while art includes, understanding patients needs and concerns and doing actions to enhance patients ability. We became very sensitive to our patients need during our nursing care. We tried to foresee possible things/complications that could happen to our client so that immediate nursing actions could be establish. We also became his advocate, even though his subjective data didnt match the objective data that we assessed, still we did accurate and proper interventions and referrals to the staff nurses and clinical instructor.

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Books: Textbook of Medical-Surgical Nursing 11th edition by Brunner and Suddarth Volume II Medical Surgical Nursing 8th edition by Black and Hawks Volume II Microbiology an Introduction 8th edition by Tortora, Funke and Case Health Assessment and Physical Examination 3rd edition by Estes Nursing Theories 2009 Lippincotts Nursing Drug Guide by Karch Merriam-Websters Medical Dictionary Microsoft Encarta 2009.

Websites: http://digestive.niddk.nih.gov/ddiseases/pubs/cirrhosis/

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