LIVER CIRRHOSIS ACUTE ANEMIA SECONDARY TO UPPER GASTROINTESTINAL BLEEDING

In partial fulfillment of the requirements in NURS65b Medical Surgical Nursing Submitted to the level III Clinical Instructors of the College of Nursing, Cavite State University, Indang, Cavite Presented by: BSN Level III/Group2 Al-ghorani, Areej S. Dimaranan, Zaira Joy D. Foliente, Jayson P. Jaleco, Cristy Belle D. Losoloso, Bethlehem Marqueda, Jessa Redruco, Nheafe Reden Salamatin, Anna Marie L. Sarabia, Rachelline Trupel, Janah Nicole

ABSTRACT We, BSN 3 section 1, group 2 chose Liver Cirrhosis, Acute Anemia secondary to UGIB as our case for the case presentation because this is the patient who had the most significant disease out of all the patients that we handled in GEAMH medical ward during our three day shift. This patient is challenging for us because we need deeper understanding and proper management in order to provide a safe and quality nursing care. The purpose of this case study is to learn the disease process, its management, medications and treatment. Here is a brief introduction and overview of what Liver cirrhosis is all about. Cirrhosis is a complication of many liver diseases that is characterized by abnormal structure and function of the liver. The diseases that lead to cirrhosis do so because they injure and kill liver cells and the inflammation and repair that is associated with the dying liver cells causes scar tissue to form.

 The liver cells that do not die multiply in an attempt to replace the cells that have died. This results in clusters of newly-formed liver cells (regenerative nodules) within the scar tissue. There are many causes of cirrhosis; they include chemicals (such as alcohol, fat, and certain medications), viruses, toxic metals (such as iron and copper that accumulate in the liver as a result of genetic diseases), and autoimmune liver disease in which the body's immune system attacks the liver. Patients with cirrhosis may have few or no symptoms and signs of liver disease. Some of the symptoms may be nonspecific, that is, they don't suggest that the liver is their cause. Some of the more common symptoms and signs of cirrhosis include: Yellowing of the skin (jaundice) due to the accumulation of bilirubin in

 the blood, Fatigue, Weakness, Loss of appetite, Itching, and Easy bruising and bleeding from decreased production of blood clotting factors by the diseased liver. Alcohol is a very common cause of cirrhosis, particularly in the Western world. The development of cirrhosis depends upon the amount and regularity of alcohol intake. Chronic, high levels of alcohol consumption injure liver cells. Thirty percent of individuals who drink daily at least eight to sixteen ounces of hard liquor or the equivalent for fifteen or more years will develop cirrhosis. Alcohol causes a range of liver diseases; from simple and uncomplicated fatty liver (steatosis), to the more serious fatty liver with inflammation (steatohepatitisor alcoholic hepatitis), to cirrhosis. Our patient manifested some of the symptoms of Liver cirrhosis specifically bleeding. He had been excessively drinking alcoholic beverages which lead to his condition. His condition will be further evaluated and assessed as we go along in this case study.

Initials of the client: R.R.A. Address: 1B Malagasang Imus Cavite Date of Interview: March 13, 2013 4:00 p.m. Age: 49 years old Primary Informant: R.R.A. Birth date: June 20, 1963 Other Data Sources: Patients Chart Birth Place: Pabella Sta. Cruz Blood Type: O Rh(+) Gender: Male Civil Status: Single Religion: Roman Catholic Highest Educational Attainment: High School Graduate Current Occupation: Pedicab Driver Monthly Family Income/Budget: pesos Everyday Income: Php250-Php300 Income allotment: * Electric bills- Php500-Php700 * Water bills- Php150-Php250 * Food Allowance-Php500-Php1000 *Everyday Expenses- Php200-Php250 Usual Source of Medical Care: Hospital check-ups Medical Support: Philhealth

 March 9, 2013, 8:35 in the evening patient R.R.A. was admitted in General Emilio Aguinaldo Hospital with his brother as a new patient due to passing bloody stools and abdominal pain.

 January 2010, patient was first admitted in Philippine General Hospital due to abdominal pain. He was diagnosed with a liver problem. June 2010, patient had a fever and experienced recurrent abdominal pain and bloated stomach, but did not consult any medical advice and care. He did not visit follow up check up. He stayed at home until his stomach subsides. March 2013, a week prior to hospitalization R.R.A. drank alcohol. 2 days PTA patient had abdominal pain. 1 day PTA, patient had continuous abdominal pain associated with bloody stools. He was sent to the emergency room of GEAMH at 8:35 pm on March 9, 2013.

PAST MEDICAL HISTORY The patient does not have any serious childhood diseases except for measles; he also had coughs and colds like any other child. According to the patient, he had complete immunizations when he was a child. He already had 1 dose of Tetanus toxoid due to his current accident. The patient has no known allergies. February 7, 2013, at exactly 7:00 a.m. he was hit and run by a motor vehicle with slight lesions on his extremities and does not go to hospitals instead he stayed at home and rested there with his mother taking care of him. March 3, 2013 in the evening, while R.R.A. is drunk and riding his bicycle, the patient had an accident and fell, and hit his head. The patient was sent to General Emilio Aguinaldo Hospital for treatment. He was first hospitalized at Philippine General Hospital on June, 2010 and was diagnosed with Liver dysfunction. Second hospitalization was at General Emilio Aguinaldo Hospital on March 9, 2013 due to liver Cirrhosis. The patient had not undergone any operations and surgeries as of now. The clients medication are as follows: Vit. K, Tranexamic Acid, Rebamipide, Moriamin forte-calcium pantothenic, Livoline, albumin, furosemide, lactulose and omeprazole.

 I. Health Perception Health Management Pattern II. Nutritional Metabolic Pattern III. Elimination Pattern IV. Activity Exercise Pattern V. Sleep Rest Pattern VI. Cognitive Perceptual Pattern VII. Self- Perception Pattern VIII. Role Relationship Pattern IX. Coping Stress Pattern X. Value Belief Pattern

I. Health Perception Health Management Pattern

Patient R.R.A. perceives health as important part in his life and said that he loves to live so also as life. Prior to admission, he believes that he is in good health and that he has good quality of resistance. He does exercises like biking every morning for almost 30 minutes and eating healthy foods in maintaining a healthy lifestyle. He has no known allergies so far. And when he had illness, he drinks medicine like Bioflu and Biogesic. He said that taking those medicines are helpful enough to treat his illness. R.R.A. does not use any herbal medicines since it is not available in their place. He started smoking since high school at the age of 13, according to him it is because of peer pressure. Since then, he can consumed 1 pack of cigarette per day. He also said that he can drink a case of alcohol by himself. He was circumcised at the age of 12 years old when he was on Grade 6.

 Upon hospitalization, patient still perceives health as an important part of life. He is aware that drinking alcohol and smoking cigarettes is not a healthy lifestyle, but since he was influenced and addicted with it, he couldnt resist from taking such. He is now taking too many medications to keep him healthy and to prevent further complications on his illness. He said that he wants to go home to do those past activities that he is doing before and is complaining of feeling of boredom.

II. Nutritional Metabolic Pattern

The patient usually eats rice, vegetables, meat and sea foods. Prior to admission the last food that he ate was sardines and 2 cups of rice. He loves to eat and his favorite dishes are sinampalukang manok, calderetang spare ribs and pancit palabok. He also stated that he ate 6 meals and drinks 6 liters of water a day. He does not take any supplements or vitamins. He used to weigh 65kgs. before but now that he was hospitalized he thinks that he lost some of his weight. He does not experience any discomfort or problems in swallowing. Patient R.R.A is ectomorph. He was on NPO for 3 and half days and after that he was ordered to have a clear diet. He only got his nutrients from the dextrose that was put in to him.

III. Elimination Pattern

Prior to hospitalization, R.R.A. usually defecates every morning with a firm, brownish in color feces. And has no problem in controlling his bowel and has no discomfort in defecating. He eliminates urine several times a day, usually yellowish in color depending on the amount of fluids he takes. Has no problem in controlling and eliminating his urine. Does not lose bowels and urine when he does not want to. Has no excess perspiration and body odor. There is no body cavity drainage attached to the patient. The day before his admission, he experienced passing bloody stools. Upon hospitalization, patient R.R.A. has difficulty in passing stools thats why he was ordered to be given laxatives and suppositories to help him defecate. He only defecated 2 times since admission. Because the client is in NPO so we can expect that he has a hard stool.

IV. Activity Exercise Pattern

According to patient R.R.A. he has sufficient energy enough for his desired activities at home and at his work. He is a very active person back then that he used to bike and work for his parents. His means of exercise is through biking for almost 30 minutes every day. He spends his spare time by staying with his friends house and chatting with them. He is also fond of drinking alcohol and smoking cigarettes with his friends.

KATZ Index
Activities Independence = 1 pt. Dependence = 0 pt.

Bathing
Dressing Toileting Transferring Continence Feeding Total Points:

1
1 1 1 1 1 6

The table above shows that patient can do most of the activities of daily living. He is independent to his caregiver or significant other when it comes to moving or doing simple activities such as transferring, toileting and feeding before and during hospitalization.

V. Sleep Rest Pattern

Patient R.R.A said that he usually goes to sleep at 12 midnight and wakes up at 7am and he feels rested and ready for daily activities. According to him he does not have any problems in sleeping. He does not snore. He also added that he frequently had dreamt of being fell. He sometimes wakes up at dawn just to void. Upon hospitalization the patient said that he is not getting his usual sleeping pattern like before. The patient cant sleep well because of the humid temperature at the hospital and also he is unfamiliar with his surroundings that is why he feels not fully rested in the morning. He does not use any sleeping aids to promote sleep.

VI. Cognitive Perceptual Pattern

The patient complains of having pricking pain in his right abdomen. That occurs after he had drunk again alcohol that made his stomach bloated. He scored it 8 out of 10 and rests seems to help to alleviate the pain. As signs of aging, he is wearing eye glasses because he couldnt read words and phrases 12 inches away from him. He doesnt have problems in hearing, smelling and his sense of touch. He said that he has a good memory with regards with dates. And is aware of the current events and issues in his country. He has no problems in concentration. And has no learning disability. He learns best through personal experiences.

VII. Self- Perception Pattern

As stated by the patient he is a joyful person he loves to make people laugh. And most of the time feels good about his self. His vocabulary in life is that if he thinks he can do it he will probably make more than of it. When he was a child he likes to be outside their house and play with other children. He said that he is kind and approachable person. When he got problems he tried to calm his self and he thinks optimistically. He said that as soon as he get discharge he will find a work and will spends most of his time with his family not with his friends. He thinks that sometimes he get a little bit odd with people but he assure that he will not harm any of his family.

VIII. Role Relationship Pattern

According to the patient his family was always mad at him because of his consistent vice of drinking alcohol. He also added that he take drugs before. He lived with his mother and father because he is still single. And they have a nuclear type of a family. He is not married yet and is not planning to have marriage. In his hospitalization right now, her sister and other siblings are the ones managing the expenses in the hospital. When he has problems he asks for the help of his older sister and his friends. He solved his and their familys problem by talking over with it. He thinks that his mother doesnt like him at all. The client wanted to go home because he feels lonely and he wished to see his parents. He thinks that he cant court any girls anymore because of his age. He does not feel isolated from his neighborhood but misjudge because of his vices.

IX. Coping Stress Pattern

R.R.A. has someone with him whom he can talk to but there are times that he just wanted to be alone to think. He likes to help his family in terms of financial needs. He said that now his family is always there by his side to support him. The patient never thought of committing suicide because he enjoys life. When he is stressed he just finds a place where he can think and also eat the foods that he likes.

X. Value Belief Pattern

Generally, patient gets those things he wants since he is earning money by himself. Most important part of his life is his parents. The patient is a Catholic. According to him when he got sick he always prays but after he recovered he will not do the usual thing he do when he is sick and he admits that. Now he realized the importance of having God in our life and we should always have a strong faith to God. At present he prays before going to sleep.

PHYSICAL EXAMINATION

DIAGNOSTIC TEST

Patient Initial: R.R.A Age: 49 y/o Diagnosis: Liver Cirrhosis, Acute Anemia 2 o to UGIB HEMATOLOGY REPORT EXAM DATE; 3/09/2013 3:05 pm
UNIT
9.10 2.37 75.0 20.9 88.2 31.6 35.9 152 73.4 16.0 8.0 2.4 0.2 15.1 10.3 10^3/uL 10^6/uL G/L % fL pg g/dL 10^3/uL % % % % % % fL

TEST
WHITE BLOOD CELLS RED BLOOD CELLS HEMOGLOBIN HEMATOCRIT MCV MCH MCHC PLATELET Neutrophil (%) Lymphocytes (%) Monocytes (%) Eosinophils (%) Basophils (%) RDM CV MPV

RESULT

REFERENCES
5.0 10.0 M 4.7-6.1 F 4.0 5.5 M 135 180 F 120 ;.160 M 42.0 52.0 F37.0 47.0 M 80 -94 F 81-99 27.0 31.0 33.0 37.0 150 450 50.0 70.0 25.0 40.0 3.0 11.0 1.0 4.0 0.0 1.0 11.5 14.5 7.2 11.1

March 10 TIME RECEIVED: 5:00 AM TIME FINISHED: 9:30 AM

CLINICAL CHEMISTRY COBAS INTEGRA 400 PLUS Generated Result

Test GLUCOSE (FASTING) CHOLESTEROL

Result 5.42 2.67

Reference Ranges 4.11 5.89 mmol/L Up to 5.2 mmol/L

TRIGLYCERIDES
HDL

0.25
0.986

Up to 2.3 mmol/L
M greater than 1.45 mmol/L F greater than 1.68 mmol/L Less than 2.59 mmol/L Less than 1.04 mmo/L M 40 -129 U/L F 35 104 U/L

LDL VLDL ALK. PHOS.

1.6 0.11 157.4

EXAM DATE; 3/11/2013 11: 36 am

TEST WHITE BLOOD CELLS RED BLOOD CELLS HEMOGLOBIN HEMATOCRIT MCV MCH MCHC PLATELET Neutrophil (%) Lymphocytes (%) Monocytes (%) Eosinophils (%) Basophils (%) RDM CV MPV RETICULOCYTE COUNT ERTHROCYTE SEDIMENTATION RATE CLOTTING TIME BLEDDING TIME RESULT 4.01 3.11 98.0 29.0 93.2 31.5 33.8 228 62.9 23.2 9.0 4.7 0.2 16.1 10.0 UNIT 10^3/uL 10^6/uL G/L % fL pg g/dL 10^3/uL % % % % % % fL % MM/HR MIN MIN REFERENCES 5.0 10.0 M 4.7-6.1 F 4.0 5.5 M 135 180 F 120 160 M 42.0 52.0 F37.0 47.0 M 80 -94 F 81-99 27.0 31.0 33.0 37.0 150 450 50.0 70.0 25.0 40.0 3.0 11.0 1.0 4.0 0.0 1.0 11.5 14.5 7.2 11.1 ADULT 1-2 INFANT 4-8 M 0 10 F 0-20 24 24

CLINICAL CHEMISTRY COBAS INTEGRA 400 PLUS Generated ResultaA Test Result Reference Ranges GLUCOSE 5.21 4.11 5.89 mmol/L CHOLESTEROL 3.21 Up to 5.2 mmol/L TRIGLYCERIDES 0.41 Up to 2.3 mmol/L HDL 1.089 M greater than 1.45 mmol/L F greater than 1.68 mmol/L LDL 1.9 Less than 2.59 mmol/L VLDL 0.19 Less than 1.04 mmo/L SGOT (AST) 70.2 M up to 40 U/L F up to 32 U/L SGPT (ALT) 33.0 M up to 41 U/L F up to 33 U/L ALK. PHOS. 131.4 M 40 -129 U/L F 35 104 U/L T. PROTEIN 66.60 64 83 g/L ALBUMIN 51.23 35 52 g/L GLOBULIN 15.41 23 35 g/L A/G Ratio 3.3 1.1 2.5 g/L T. BILIRUBIN 12.70 Less than 17.0 umol/L D. BILIRUBIN 6.64 0 3.4 umol/L IND. BILIRUBIN 6.02 1.7 10.1 umol/L

DATE: MARCH 13 2013 TIME RECEIVED: 6AM TIME RELEASED: 7:40AM

CLINICAL CHEMISTRY COBAS INTEGRA 400 PLUS Generated Result Result Reference Range

Test

T. PROTEIN
ALBUMIN GLOBULIN A/G Ratio

27.3
6.49 20.81 0.31

64 83 g/L
35 52 g/L 23 35 g/L 1.1 2.5 g/L

ANATOMY and PHYSIOLOGY

PATHOPHYSIOLOGY

DRUG STUDY

NURSING CARE PLAN

Prioritization of the problem
Actual problem 1. Abdominal Pain 2. Elevated blood pressure 3. Poor hygiene 4. Disturbed sleep pattern 5. Impaired Skin Integrity 6. Impaired Dentition Potential Problem 1. Risk for Imbalanced Nutrition: less than body requirements 2. Risk for bleeding

NURISNG CARE PLAN: Acute Pain

Assessment
Subjective Data: Sumasakit yung bandang dito ko. Kumikirot na parang tumitibok ganun. Objective Data: Vital signs of: T: 36.9 PR: 78 RR: 20 BP: 160/100 (+) mild pricking pain @ Right upper quadrant of abdomen Pain scale of 4 out of 10 with 10 as severely painful. Hard to palpate abdomen (+) facial grimace (+) restless

Diagnosis
Acute pain related to splenomegaly and liver inflammation as evidenced by hard to palapate abdomen, mild pricking pain @ right upper quadrant of abdomen, restlessness and irritability secondary to liver cirrhosis.

Planning
Short term: After 2 hours of nursing intervention, the patient should have decreased level of pain from 4/10 to at least 1 2/10, and should have lesser signs of irritability, facial grimace and restlessness. Long Term: After nursing intervention, the patient should have understood the techniques and methods that can be done in order to reduce pain, and to maintain and practice the relaxation methods used at times of discomfort.

Intervention
Independent Nursing intervention: 1. Introduced self and established rapport with the patient. 2. Monitored and recorded vital signs 3. Assessed level of pain, location, and characteristic. 4. Positioned the patient in a comfortable position 5. Instructed the patient to do deep breathing exercises when in pain. 6. Rendered health teaching about some of the relaxation methods that can be used to lessen pain. Dependent Nursing intervention: 1. Assisted during giving of medications for pain. Collaborated Nursing intervention 1. Advised the guardian to help the patient at times of pain and to always be at bed side. 2. Instructed the guardian to immediately report any untoward signs and symptoms. -

Rationale
To gain trust from the patient For base line data. Assessment of pain for additional data To promote comfort and lessen pain sensation. In order for the patient not to feel too much pain at times of sensation. For the patient to know what to do at times of pain, and to control pain sensation. To lessen pain and promote pain relief to the patient. Presence and care of a guardian can help lessen the pain felt by the patient. To prevent other complications and to respond immediately to the problem before it worsens.

Evaluation
Goal Met After nursing intervention, the patients pain scale lowered from 4 out of 10 to 2 out of 10.

NURISNG CARE PLAN: Elevated Blood Pressure

Assessment Subjective Data: Wala akong nararamdaman, sadyang mataas lang talaga BP ko. Objective Data: Blood pressure recordings: 03-12-13 (PM) 3:00: 160/100 5:00: 150/90 03-13-13 (PM) 3:00: 140/90 5:00: 130/80 (+) mild, pricking pain @ right upper abdomen Pain scale of 4 out of 10 with 10 as highest. Medication of Furosemide for management of hypertension. Diagnosis Decreased cardiac output related to liver inflammation and pain as evidenced by elevated blood pressure of 160/100 and pain at right upper abdomen secondary to liver cirrhosis. Planning Short term: After 2 hours of nursing intervention, the patients blood pressure should have decreased from 160/100 to at least 130/90 mmHg. Long Term: After nursing intervention, the patients blood pressure should have normalized from 150/100 to 120/80, and should have maintained normal blood pressure range.

Intervention Independent Nursing intervention: 1. Established rapport with the patient. 2. Monitored and recorded vital signs 3. Monitored blood pressure every 2 hours. 4. Provided comfort to the patient 5. Advised patient to rest. 6. Instructed patient to sit down and avoid walking and getting up from the bed frequently. Collaborated Nursing intervention 1. Advised guardians to remove stressors and any factors that may affect the patients blood pressure range. 2. Instructed the guardians to report any untoward signs and symptoms. -

Rationale To gain trust from the patient For baseline data For further assessment of px condition. To promote relief and comfort To lessen the factors that may contribute to the elevation of blood pressure. To prevent further complications and to respond to the problem immediately.

Goal Met
After nursing intervention, the patients blood pressure decreased from 160/100 to 130/80 mmHg.

NURISNG CARE PLAN: Poor Hygiene

Assessment Subjective Data: Limang na araw na akong di naliligo, ambaho ko na. Objective Data: (+) dry skin (+) foul breath odor (+) dirty nails on feet (+) oily hair (+)tooth cavity on left incisor Dirty clothes Untidy appearance Unfixed hair Yellowish teeth Diagnosis Self care deficit related to poor personal hygiene as evidenced by foul breath odor, untidy appearance, oily hair, and infrequent bathing secondary to liver cirrhosis. Planning Short term: After 1 hour of nursing intervention, the patient should look tidy and pleasing. He should have taken a bath, teeth should be brushed and hair should be fixed. Long Term: After nursing intervention, the patient should have maintained a tidy outlook with a pleasing personality. Proper hygiene techniques should be maintained and practiced even after hospitalization.

Intervention
Independent Nursing intervention: 1. Established rapport with the patient and NPI done. 2. Assessed the patients appearance and hygiene. 3. Rendered Physical examination 4. Rendered patient health teaching about proper hygiene and its importance. 5. Advised patient to take regular baths and to brush teeth for at least 3x a day. Collaborated Nursing intervention 1. Advised the guardian to always remind and encourage the patient to take a bath daily and brush teeth.

Rationale

Evaluation
Goal Met After nursing intervention, the patient took a bath and tidied himself.

To gain trust from the patient To gather more information and data to assess his condition. For base line and additional data To increase patients knowledge about proper hygiene and for him to know the techniques to keep himself tidy. To keep self tidy and clean, and to have a good personal hygiene. To maintain patient hygiene and to remind him to keep hi

NURISNG CARE PLAN: Disturbed Sleep Pattern

Assessment Subjective Data: hindi ako nakakatulog ng maayos dito. Namamahay kasi ako eh. Objective Data: Sleep hours before hospitalization: 7 8 hours Sleep hours after hospitalization: at least 3 4 hours Interrupted sleep at night (+) restlessness (+) irritability Diagnosis Disturbed sleep pattern related to Unfamiliar sleep surroundings and lighting as evidenced by interrupted sleep hours of at least 3 hours, restlessness, and irritability. Planning Short term: After 1 hour of nursing intervention, the patients sleep hours should increase from 3 4 hours to at least 8 hours. Signs of irritability and restlessness should be lessened. Long Term: After nursing intervention, the patient should have a regular sleeping pattern and no signs of restlessness and irritability.

Interventiona Independent Nursing intervention: 1. Established rapport with the patient. 2. Rendered physical examination. 3. Interviewed the patient regarding his sleeping habits and pattern. 4. Provided comfort to the patient. 5. Suggested diversional activities before sleep such as listening to classical music or reading a book. 6. Advised patient to use eye cover if the room is too bright, and to pray before sleeping. Collaborated Nursing intervention 1. Advised guardian to keep the surrounding quiet and peaceful.

Rationale

Evaluation Goal Partially Met After nursing intervention, the patient had decreased signs of restlessness and irritability but was not able to sleep continuously for 8 hours.

To gain trust from the patient For base line data To gather more information regarding the patients concern To promote relief to patient To help the patient to sleep, and to stimulate eyes in order for the patient to have continuous sleep. To help the patient to sleep properly.

NURISNG CARE PLAN: Impaired Skin Integrity

Assessment Subjective Data: May sugat ako sa ulo tsaka marami akong peklat dahil na rin sa pagbibisikleta Objective Data: (+) wound @ left parietal side of the head (+) dry skin Poor skin turgor Thin in appearance Inadequate food intake 6 glasses of water a day Diagnosis Impaired skin integrity related to presence of wound and imbalanced nutritional state as evidenced by wound at left parietal side of the head, dry skin, poor skin turgor, and inadequate food intake, secondary to liver cirrhosis. Planning Short term: After nursing intervention, the patients skin should be moist and wound should be cleaned and disinfected. Long Term: After nursing intervention, the patient should have maintained integrity of skin by keeping it moist and cleaned daily.

Intervention Independent Nursing intervention: 1. Established rapport with the patient 2. Rendered physical examination 3. Assessed patients wound on the head 4. Performed wound care to the patient and provided frequent skin care 5. Informed and demonstrated the proper wound dressing to the patient and guardians 6. Advised patient to avoid use of soap and alcohol based lotions. 7. Advised patient to take a bath daily. Collaborated Nursing intervention 1. Instructed the guardian to perform wound care and assess skin of the patient from time to time. -

Rationale To gain trust from the patient For base line data To gather more information and data to assess his condition To prevent infection

Evaluation Goal Met After nursing intervention, the patients skin appeared moist and the wound was cleaned. The patient understood and complied with the health teaching of the student nurse.

To ensure continuity of care

To keep the skin moist and hydrated To ensure continuity of care and to prevent further complications.

NURISNG CARE PLAN: Impaired Dentition

Assessment Subjective Data: Kulang na talaga yung ngipin ko. Di na ako nagpupustiso kasi nawala ko. Pero dati may pustiso ako. Objective Data: Incomplete number of teeth: 10 (+) tooth cavity: left lower incisor (+) foul breath odor Yellowish teeth Not frequent tooth brushing: 4 times a week. Excessive Alcohol intake: 1 2 cases per session Diagnosis Impaired dentition related to ineffective oral hygiene and dietary habits as evidenced by halitosis, teeth discoloration, dental carries, and non frequent tooth brushing. Planning Short term: After 1 hour of nursing intervention the patient should have no foul breath odor and should have white teeth. Long Term: After nursing intervention, the patient should have continued the use of dentures and should have a regular check-up with the dentist.

Intervention

Rationale

Evaluation

Independent Nursing intervention: 1. Established rapport with the patient. 2. Rendered physical examination 3. Assessed the patients dentition, teeth, and mouth. 4. Advised patient to brush teeth for at least 3 times daily. 5. Advised patient to continue use of dentures and to visit a dentist for every 6 months. Collaborated Nursing intervention 1. Advised patient for referral to a dentist for complete check up and for replacement of dentures.

To gain trust from the patient For base line and additional data To gather more information and data to assess his condition To keep teeth healthy and clean. To have a proper consultation about dentition and to prevent further complications and cavities. For continuity of care and for further assessment of the patients condition.

Goal partially Met After nursing intervention, the patient does not have foul breath odor but the teeth is still yellowish.

NURISNG CARE PLAN: Risk for Imbalanced Nutrition: Less than body requirements
Assessment Subjective Data: Limang araw na akong hindi kumakain. Tubig lang daw pwede sa akin eh. Objective Data: Ectomorph (+) dry skin (+) dry lips (+) pale conjunctiva Poor skin turgor Pure water intake of at least 6 glasses a day Diagnosis Risk for imbalanced nutrition less than body requirements related to inadequate food intake secondary to liver cirrhosis. Planning Short Term : After one hour of nursing intervention, the patient should have understood the importance and risks of proper diet and nutrition. Long Term: After nursing intervention, the patient should restore old eating habits and have sufficient nutrition that the body needs.

Intervention
Independent Nursing intervention: - Established rapport with the patient - Rendered physical examination. - Maintained patients clear liquid diet. - Listened to the patients verbalization of concerns - Explained the importance of maintaining the diet prescribed to the patient. - Encouraged the patient to endure diet until his condition was already stabilized. Collaborated Nursing intervention - Advised guardian not to feed the patient solid food unless the doctors diet order was changed.

Rationale

Evaluation
Goal Met After nursing intervention, the patient understood the importance of proper nutrition and its risks.

To gain trust from the patient. For base line data As prescribed by the physician

To promote comfort and to provide an outlet for the patient. To provide knowledge and additional information that the patient needs. To prevent further complication and problems to the patient.

NURISNG CARE PLAN: Risk for Bleeding

Assessment
Objective Data: With history of upper gastro intestinal bleeding With history of Hematochezia (blood in stool) prior to admission Medications of: Vitamin K Tranexamic acid For blood clotting Laboratory result before blood transfusion: Platelet count of 152 (normal 150 450) : near to minimal range Blood transfusion of Packed RBC on March 10, 2013

Diagnosis
Risk for bleeding related to scarring of upper gastro intestinal tract due to liver cirrhosis.

Planning
Short term: After 1 hour of nursing intervention, the patient should be free from signs of bleeding. Long Term: After nursing intervention, the patient should not have any reports of recurrent bleedings.

Intervention Independent Nursing intervention: 1. Established Rapport and NPI with the patient. 2. Checked laboratory results specifically CBC with PC. 3. Watched out in giving medications that can cause bleeding. 4. Advised patient not to eat dark colored foods such as chocolates, coffee, and cola. Dependent Nursing intervention: 1. Assisted on giving of medications for preventing bleeding. Collaborated Nursing intervention 1. Advised the guardian not to feed patient dark colored foods and to immediately report signs of bleeding. -

Rationale To gain trust from the patient To gather more information about the patients condition To prevent aggravating signs of bleeding Dark colored foods, once digested, will have the same color in the stool and can be mistaken as blood. To control signs of To prevent misconception and further complications to the patient.

Evaluation Goal Met After nursing intervention, the patient did not have any signs of bleeding.

PROGRESS NOTES
XIV. PROGRESS NOTES Patient: R. R. A. Diagnosis: Liver Cirrhosis, Acute Anemia secondary to UGIB
On the first day of our duty that is on March 11, 2013 Monday in GEAMH (General Emilio Aguinaldo Medical Hospital), we handle our client RRA in the medical ward with the diagnosis of Liver Cirrhosis, Acute Anemia, secondary to (UGIB) upper gastrointestinal bleeding. We received the patient awake in bed in a sitting position with IVF PNSS 1L level 300cc@ Left metacarpal vein regulated @ 31-32gtts/min. He is conversant and ambulatory upon the interview, but he feels irritable on that time because of hot atmosphere in the medical ward it makes him uncomfortable feelings. After assessing the patient condition and NPI is done, we take the initial vitals sign of the patient. There are all-normal in v/s except his BP it increase in 140/90. We immediately refer to the staff nurse about the increase BP of our patient. In addition, to alleviate the uncomfortable feelings of our clients, we established rapport to the patient and provided therapeutic communication. We also encouraged the patient to verbalize his feelings to relieve his uncomfortable feelings. When the patient felt relax and rested, we do the physical assessment thoroughly.

On the second day our duty that is on March 12, 2013 Tuesday, after the endorsement we received our patient awake on bed in a supine position with an IVF PNSS 1L with incorporated with B-complex at the level of 250cc regulated at 31-32gtts/min, he is conscious and coherent. Again, we take the initial vital signs of our patient his BP is 130/80, which is lower than on the first day. We do again nursing patient interaction. Then, during the interview, he told as that he feels abandoned, and he missed her parents very much. We advised him to do some diversional activities such as, talking with the other patients and listening to music. We also encouraged him to relax and avoid thinking of stressful things to lessen his loneliness. After a while, one of his relative visited him in the medical ward, our patient feel better and happy.

On the third day of our duty that is on March 13, 2013 Wednesday, we continued our health teaching to our patient. We taught and remind them about the prevention of complications that can be accomplished by treating his liver cirrhosis secondary to upper gastrointestinal bleeding through taken the medication prescribed by his doctor. We also advised to stop smoking, do exercise as needed or resuming activities of daily living that can still be done by the patient, and the reduction in salt and alcohol intake.

MEDICATION

The patient advised to follow and take the prescribed medication regimen needed to the prompt recovery and effective treatment. Teachings and giving information about medicines adverse effects and its side effects are also put into practiced. The following medications were prescribed as follows: Lanexamic acid Rebamibide Furosemide Omeprazole Morlam forte Vit.K

ENVIRONMENT/ EXERCISE

Advised the patient to have a safety environment

and avoid hazardous places to keep away from

further injury or accident. Instructed the patient to do exercises and relaxation technique as tolerated such as walking, yoga and meditation.

The patient will have no restrictions to physical

activities; however, the patient should pay attention to their body in reaction to certain activities. Gradually increase activities at a

comfortable and individual pace.

TREATMENT Instructed the patient to comply the long-term treatment for his condition and to monitor the

possible sign and symptoms of the disease.

HYGIENE Instructed the patient to do proper hygiene such as, take a bath every day, trimming the nails, changing clothes everyday and brushing his teeth after eating.

OPD

The patient instructed to have his follow-up check-up with a hepatologist or gastroenterologist in the OPD for his quick recovery.

DIET

Encouraged patient to avoid fatty/oily foods; avoid sour food and drinks. Avoid spicy foods otherwise nothing by mouth if with persistent abdominal pain. Encouraged patient to increase fluid intake. Encouraged patient to eat foods rich in vitamins and nutritious foods. Recommending dietary changes of decreased/avoiding fat intake is prudent; this may decrease the incidence of gastrointestinal bleeding. Since maximum liver function is essential for proper bile formation, it is also important to reduce chemical stress upon the liver (remember, the liver produces the bile which must have proper levels of cholesterol, bile acids and lecithin and synthetic chemicals are well known for weakening liver function).

SPIRITUAL CARE

Advised the patient to read spiritual and uplifting books. Think about what you read, and find out how you can use the information in your life Meditate for at least 15 minutes every day. Learn to make your mind quiet through concentration exercises and meditation.

Acknowledge the fact that you are a spirit with a physical body, not a physical body with a spirit. If you can really accept this idea, it will change your attitude towards many things in your life. Look often into yourself and into your mind, and try to find out what is it that makes you feel conscious and alive. Advised the patient to think positive. If you find yourself thinking negatively, immediately switch to thinking positively. Be in control of what enters your mind. Open the door for the positive and close it for the negative.

Develop the happiness habit, by always looking at the bright side of life and endeavoring to be happy. Happiness comes from within. Do not let your outer circumstances decide your happiness for you. Exercise often your will power and decision making ability. This strengthens

you and gives you control over your mind.