SISTER NIVEDITA GOVERNMENT NURSING COLLEGE

IGMC SHIMLA

SUBJECT :- CHILD HEALTH NURSING

CASE PRESENTATION
ON
LIVER ABSCESS

SUBMITTED TO SUBMITTED BY

MRS. SEEMA CHAUHAN NIKSHUCHAUDHARY

C.I.CUM.S.T M.SC.NURSING 1ST YEAR
S.N.G.N.C., IGMC SHIMLA S.N.G.N.C., IGMC SHIMLA

SUBMITTED ON

2-02-19
 CASE PRESENTATION

Patient’s Profile
1. IDENTIFCATION DATA:

1. Name of the patient: Baby of Harnoor Sethi

2. Name of informant: Mrs. Harnoor Sethi( Father)
3. Father’s name: Mr.Hardeep Sethi
4. Age/ Sex: 2 month/ Male
5. Date of admission: 12/01/19
6. IPD NO.: 2418770
7. OPD NO.: 180824105808047
8. Doctor in charge: Dr. Satish Agarwal
9. Religion: Hindu
10. Educational qualification: None
11. Occupation: None
12. Diagnosis: Liver Abscess

13. History of illness:

a. History of the present illness: The parents presently complaint of having:

 Fever
 Anorexia
 Decreased urine out put
 Cough
b. History of past illness (surgical): Patient Baby of Harnoor Sethi had no past surgical history
of illness.
c. History of family past illness (medical and surgical):- Patient family had no history of
hypertension, diabetes mellitus and any other problem.
d. Family history:

Sr. Name of the family Age/ Sex Relation Education Remarks

No. member with the
patient
1. Mr. Hardeep Sethi 35/ Male Father Graduate Healthy

2. Mrs. Harnoor Sethi 28Y/ Female Mother Graduate Healthy

3. Baby of Harnoor 2 month / Patient ---------- Unhealthy( Liver
Sethi Female abscess)

Family tree:

Keys:
Mr. Hardeep Sethi Mrs. Harnoor Sethi Male

(Father) (Mother)
Female

Patient Patient

14. Child’s Personal data:

a. Obstetrical history of mother: Mr. Harnoor Sethi had no bad obstetrical history and
delivered a healthy baby.
b. Prenatal and natal history: The mother has done 2-3 antenatal checkups. The mother has
taken 2 doses of tetanus toxoid during antenatal checkup and took iron and folic acid tablets. The
mother has delivered a child with the normal vaginal delivery without any complication.
c. Growth and development:

Sr. No. Measurement Child’s picture Normal picture Remarks

1. Height 37.5 cm 59.1 cm Abnormal
2. Weight 4 kg 5.1-7.9 kg Underweight
3. Head circumference 34 cm 40 cm Normal

4. Chest circumference 33cm 33-35 cm Normal

5. Mid-arm circumference 11.5cm 13cm Malnourished

d. Development mile stone of the development: There is normal developmental milestone. i.e
running, walking, sitting, crawling but has partial head control.
e. Social , emotional and language development: Patient had started social smile, Smile in
recognition and recognize mother’s coos an gurgles.
f. Immunization status: The child is immunized up to 6 weeks.

AGE VACCINES DATE REMARKS

Birth  BCG -----------  Given

 OPV zero  Given
 Hepatitis B-1  Given
6 weeks  OPV-1+ IPV- -------------  Given
1/OPV-1
 Hepatitis B-2  Given
 HIB-1  Given

g. Dietary pattern: The child is totally depend up on oral feeding.

h. Play habits: There is no any specific habit of playing.

i. Toilet training: Baby’s bowel pattern is not normal. The patient is sudden constipation
following an acute episodes of diarrhea.

j. Sleep pattern : The child had disturbed sleeping pattern i.e. 5-6 hours.

k. Schooling: None
15. Socioeconomic status:

Monthly income

Sr.No. Name of the family member Occupation Monthly income

1. Mr. Hardeep Sethi Business man 800000/ MONTH

Mr. Hardeep Sethi head of the family member is earning monthly income in rupees 80,000 and
total expenditure Rs 35,000 /- and they save Rs. 45,000 per month, so there socioeconomic status
is good.
 Physical Assessment
1. Baseline data:
1. Weight : 4 kg
2. Length : 52 cm
3. Temperature : 98.2 F
4. Pulse : 140b/m
5. Respiration : 26b/m
6. Chest circumference : 40 cm

2. General appearance:
1. Nourishment : Patient is malnourished and has poor nutritional status.
2. Body fluid : There is no edema or ascites in the patient body.
3. Health : Patient is unhealthy and malnourished.
4. Activity : The patient become bedridden.

3. Mental status:
1. Consciousness : Patient is conscious. i.e aware to person, place and time.
2. Look : Patient look weak and pallor
4. Posture:
1. Body curve : No kyphosis, lordosis and scolosis is present.
2. Movement : Patient had no active range of motion.

5. Skin condition:
1. Color : Patient look pallor in color.
2. Texture : The patient skin is dry and rough.
3. Lesion and infection : Patient had no skin lesion and infection is present.
4. Rash : No rashes is present
5. Nails : The patient nails become thin.

6. Head:
1. Hair color : Patient hair is black in color.
2. Scalp : No dandruff is present.
3. Face : Patient is weak and look bluish discoloration of face.

7. Eyes:
1. Eyebrows : The patient eyebrows become symmetrical.
2. Eyelashes : There is no infection in the patient eye.
3. Eyelids : No edema and lesion is present.
4. Eyeball : The eyeball of the patient become sunken.
5. Eye conjunctiva : There is no swelling in the patient eye( conjunctivitis)
6. Sclera : Normal
7. Cornea and iris
8. Lens : The lens became transparent.
9. Fundus : Patient become reactive towards light.
8. Ears:
1. External ear : Patient had no discharge from the ear.
2. Hearing : Hearing is normal and there is no use of hearing aids.

9. Nose:

10. Mouth and pharynx:

1. Lips : The patient lips become dry.
2. Odor of mouth : There is a bad odor from the patient mouth ( Halitosis)
3. Presence of cleft lip or cleft palate : No cleft lip and palate abnormality is present.
4. Color : The patient look pale.
5. Throat : There is secretion present in the patient throat.

11. Neck:

1. Lymph nodes : There is no lymph node enlargement present

2. Movements : There is restricted flexion and extension of the neck.
3. Thyroid gland : There is no enlargement of thyroid gland. (
hypothyroidism and hyperthyroidism)
12. Chest:
1. Expansion : There is bilateral expansion of the chest.
2. Mark of an injury : There is no mark of any injury is present

3. Surgery mark : There is surgical mark present in the patient.

13. Abdomen:
1. Inspection : Absence of skin rashes,
2. Abdominal girth : The abdominal girth is < 80cm.
3. Palpation : Abdominal distension and tenderness is present.
4. Auscultation : Normal bowel sound is absent.
5. Percussion : Absence of any mass formation.
6. Presence of generalized edema : Edema is absent.

14. Back: Patient spine is straight and no kyphosis, lordosis and scoliosis is present.

15. Extremities:
1. Upper extremities : There is no any deformity present in the patient.
2. Lower extremities : There is no any deformity i.e. hip dislocation,
clubbed foot or any bone deformities is present.

16. Genitalia: In patient there is no any congenital anomalie i.e Undescended testis,
hypospadias, epispadias etc.
17. Rectum: There is no congenital anomalie is present i.e hemorrhoids, polyps etc.

18. Elimination pattern:

1. Bowel habits:
a. Frequency : Abnormal( 4-5 times/day)
b. Color : Clay color of stool.
2. Bladder capacity:
a. Frequency : There is abnormal urine pattern and they urinate every 3to 4 hour.
b. Color : The patient urine is pale yellow in color.
c. Amount : Amount of urine is approaximate 40ml.
 DISEASE CONDITION

Definition:-

Liver abscess is a collection of pus fluid thick, yellowish caused by bacterial, protozoal or fungal
invasion into the tissues of the body. Abscesses may occur in the skin, gums, bones, and organs
such as the liver, lungs, and even the brain, an area that occurred abscess red and puffy, there is
usually a sensation of pain and local heat.

OR
Liver abscess is a form of infection in the liver caused by a bacterial infection, parasites , fungi
and sterile necrosis originating from the gastrointestinal tract characterized by the process of
suppuration with the formation of pus in the liver parenchyma.

Anatomy and physiology:

Liver is the body’s second largest organ; only the skin is larger and heavier. The Liver is an
organ on the right side of the body weighing about 1.5Kg. It is distinctly the largest and a key
organ of a human body, characterized by its muddy red colour. It is strategically the first port of
entry from the process of digestion before nutrients leave for the rest of the body. It is the only
organ in the human body that can regenerate unless struck by disease. The liver performs many
essential functions related to digestion, metabolism, immunity, and the storage of nutrients
within the body. These functions make the liver a vital organ without which the tissues of the
body would quickly die from lack of energy and nutrients. Fortunately, the liver has an
incredible capacity for regeneration of dead or damaged tissues; it is capable of growing as
quickly as a cancerous tumor to restore its normal size and function.

Anatomy of the Liver

Gross Anatomy
The liver is a roughly triangular organ that extends across the entire abdominal cavity just
inferior to the diaphragm. Most of the liver’s mass is located on the right side of the body where
it descends inferiorly toward the right kidney. The liver is made of very soft, pinkish-brown
tissues encapsulated by a connective tissue capsule. This capsule is further covered and
reinforced by the peritoneum of the abdominal cavity, which protects the liver and holds it in
place within the abdomen.
The peritoneum connects the liver in 4 locations: the coronary ligament, the left and right
triangular ligaments, and the falciform ligament. These connections are not true ligaments in the
anatomical sense; rather, they are condensed regions of peritoneal membrane that support the
liver.

 The wide coronary ligament connects the central superior portion of the liver to the
diaphragm.
 Located on the lateral borders of the left and right lobes, respectively, the left and right
triangular ligaments connect the superior ends of the liver to the diaphragm.
 The falciform ligament runs inferiorly from the diaphragm across the anterior edge of the
liver to its inferior border. At the inferior end of the liver, the falciform ligament forms
the round ligament (ligamentum teres) of the liver and connects the liver to the umbilicus.
The round ligament is a remnant of the umbilical vein that carries blood into the body
during fetal development.
 The liver consists of 4 distinct lobes – the left, right, caudate, and quadrate lobes.

 The left and right lobes are the largest lobes and are separated by the falciform ligament.
The right lobe is about 5 to 6 times larger than the tapered left lobe.
 The small caudate lobe extends from the posterior side of the right lobe and wraps
around the inferior vena cava.
 The small quadrate lobe is inferior to the caudate lobe and extends from the posterior
side of the right lobe and wraps around the gallbladder.

Bile Ducts
The tubes that carry bile through the liver and gallbladder are known as bile ducts and form a
branched structure known as the biliary tree. Bile produced by liver cells drains into microscopic
canals known as bile canaliculi. The countless bile canaliculi join together into many larger bile
ducts found throughout the liver.
These bile ducts next join to form the larger left and right hepatic ducts, which carry bile from
the left and right lobes of the liver. Those two hepatic ducts join to form the common hepatic
duct that drains all bile away from the liver. The common hepatic duct finally joins with the
cystic duct from the gallbladder to form the common bile duct, carrying bile to the duodenum of
the small intestine. Most of the bile produced by the liver is pushed back up the cystic duct by
peristalsis to arrive in the gallbladder for storage, until it is needed for digestion.

Blood Vessels
The blood supply of the liver is unique among all organs of the body due to the hepatic portal
vein system. Blood traveling to the spleen, stomach, pancreas, gallbladder, and intestines
passes through capillaries in these organs and is collected into the hepatic portal vein. The
hepatic portal vein then delivers this blood to the tissues of the liver where the contents of the
blood are divided up into smaller vessels and processed before being passed on to the rest of the
body. Blood leaving the tissues of the liver collects into the hepatic veins that lead to the vena
cava and return to the heart. The liver also has its own system of arteries and arterioles that
provide oxygenated blood to its tissues just like any other organ.
Lobules
The internal structure of the liver is made of around 100,000 small hexagonal functional units
known as lobules. Each lobule consists of a central vein surrounded by 6 hepatic portal veins and
6 hepatic arteries. These blood vessels are connected by many capillary-like tubes called
sinusoids, which extend from the portal veins and arteries to meet the central vein like spokes on
a wheel.
Each sinusoid passes through liver tissue containing 2 main cell types: Kupffer cells and
hepatocytes.

 Kupffer cells are a type of macrophage that capture and break down old, worn out red
blood cells passing through the sinusoids.
 Hepatocytes are cuboidal epithelial cells that line the sinusoids and make up the majority
of cells in the liver. Hepatocytes perform most of the liver’s functions – metabolism,
storage, digestion, and bile production. Tiny bile collection vessels known as bile
canaliculi run parallel to the sinusoids on the other side of the hepatocytes and drain into
the bile ducts of the liver.

Physiology of the Liver

 Digestion
 Detoxification
 Storage
 Immunity

Etiology: Major bacterial causes of liver abscess include the following:

 Streptococcus species (including Enterococcus)

 Escherichia species
 Staphylococcus species
 Klebsiella species (Higher rates in the Far East)
 Pseudomonas species
 Proteus species
 Entamoeba Histolytica

Pathophysiology:- The amoebic cyst is ingested

Cyst develop in to the trophozoite form in the colon

 Reaches the liver through the portal circulation

Abscess may occur may occur due to infection by bacteria

Clinical manifestations: -
The sign and symptoms of disease is-

 Swollen belly
 Vomiting, including vomiting a green or brown substance
 Diarrhea
 Chronic constipation
 Gas
 Failure to thrive
 Fatigue
 Anorexia
Diagnostic evaluation:-
 Medical history and physical examination
 Rectal examination
 Barium X- ray enema will show the segment of bowel that is constricted and obstructed.
 Biopsy: Biopsy of rectal tissue reveal the absence of nerve fibers.

Investigations:-

Sr.No. Investigation Patient value Normal value Remarks

1. Hb 6.4g/dl 12.0- 16.0g/dl Anemia
2. PCV 42.50% 36-46% Normal
3. RBC 5.18mill/mm3 3.80-4.80mill/mm3 Normal
4. TLC 14.87Thousand/mm 4-10Thousand/mm Increased
5. Calcium 10.3 mg/dl 8.2- 10.4mg /dl Normal
6. Phosphorous 4.36mg/dl 2.5-4.6mg/dl Normal
7. Creatinine 0.46mg/dl 0.6- 1.3mg/dl Normal
8. Sodium 130meq/l 132-148meq/dl Normal
9. Potassium 5.2meq/l 3.5-5.5meq/l Normal
 MANAGEMENT

Medical management:-

Sr.No Medication Dose Action Side effect Nursing

. responsibilities
1. Peperacillin 250mg Tazobactam inhibits Nausea, constipation,  Obtain
or beta lactamase and diarrhea, headche, or
history
Tazobactam prevents the trouble sleeping
destruction easy bruising/bleedin of
of piperacillin. g. hyperse
Therefore, tazobacta nsitivity
m is given with to
piperacillin to
enhance the activity peperaci
of piperacillin in lin or
eradicating bacterial other
infections. Piperacill drugs
in kills bacteria by
prior to
inhibiting the
synthesis of bacterial administ
cell walls. ration.
 Monitor
patient
carefull
y during
the first
30 min
after
initiatio
n of the
infusion
for signs
of
hyperse
nsitivity
.
 Report
rash,
itching,
 or other
signs of
hyperse
nsitivity
immedi
ately.
 Report
loose
stools or
diarrhea
 Do not
breast
feed
while
taking
this
drug
without
consulti
ng
physicia
n.

2. Rantac 6mg Rantac is a  Headache,  Take drug

competitive, constipation. with meals
reversible inhibitor  Diarrhea, and at
of the action of nausea and vomiting, bedtime.
histamine at the  stomach Therapy may
histamine discomfort or pain. continue for
H2 receptors found 4–6 weeks or
in gastric parietal longer.
cells. This results in  If you also are
decreased gastric using an
acid secretion and antacid, take
gastric volume, and it exactly as
reduced hydrogen prescribed,
ion concentration. being careful
of the times of
administration
.
 Have regular
 medical
follow-up
care to
evaluate your
response.
 You may
experience
these side
effects:
Constipation
or diarrhea
(request aid
from your
health care
provider);
nausea,
vomiting
(take drug
with meals);
enlargement
of breasts,
impotence or
decreased
libido
(reversible);
headache
(adjust lights
and
temperature
and avoid
noise).
 Report sore
throat, fever,
unusual
bruising or
bleeding,
tarry stools,
confusion,
hallucinations
, dizziness,
severe
headache,
muscle or
joint pain

3. Cephalexin 35mg Cefalexin is a beta- vaginal discharge,  Call your

 lactam antibiotic of headache, dizziness, doctor
the cephalosporin aches and pains, immediatel
family. It is confusion, mouth y if you
bactericidal and acts sores, and fatigue. experience:
by inhibiting Severe ski
synthesis of the n rash or
peptidoglycan layer swelling.
of the bacterial cell  Arrange for
wall. culture and
sensitivity
test of
infection
during and
after
therapy.
 Take this
medicine
with food.
 Avoid
alcohol
while
taking
cephalexin.
4. Loperamide 12mg Loperamide works Abdominal  Nurses hav
by decreasing the pain/discomfort, naus e an
activity of the ea, vomiting, dry mo important
myenteric plexus, uth,tiredness, drowsin role to play
which decreases the ess, dizziness, constip in patient
tone of the ation, and flatulence education
longitudinal and and follow
circular smooth up in order
muscles of the to
intestinal wall. This minimize
increases the time toxicity.
material stays in the  Patient care
intestine, allowing concerns
more water to be include
absorbed from the manageme
fecal matter. nt of
diarrhea
and nausea
and
vomiting,
neutropenia
with
related risk
 of
infection,
and fluid
and
electrolyte
imbalance
5. Ferronia 0.3mg Nausea, stomach Before
upset and abdominal using Ferronia
pain, constipation or Injection, inform
diarrhea and your doctor about
vomiting. ... your current list of
medications, over
the counter
products (e.g.
vitamins, herbal
supplements, etc.),
allergies, pre-
existing diseases,
and current health
conditions (e.g.
pregnancy,
upcoming surgery,
etc.). Some health
conditions may
make you more
susceptible to the
side-effects of the
drug. Take as
directed by your
doctor or follow
the direction
printed on the
product insert.
Dosage is based on
your condition.
Tell your doctor if
your condition
persists or
worsens. Important
counseling points
are listed below.
 History of
peptic ulcer or
severe renal
failure
 Pregnant,
 planning to get
pregnant or
breastfeeding

Surgical management:-

HEPATECTOMY:

 Hepatectomy is the surgical resection (removal of all or part) of the liver. While the term
is often employed for the removal of the liver from a liver transplant donor.


Diet management:-

 Serve high-fiber foods. If a child eats solid foods, include high-fiber foods. Offer whole
grains, fruits and vegetables and limit white bread and other low-fiber foods. Because a
sudden increase in high-fiber foods can worsen constipation at first, add high-fiber foods to
your child's diet slowly. If a child isn't eating solid foods yet, ask the doctor about formulas
that might help relieve constipation.

 Increase fluids. Encourage your child to drink more water. If a portion or all of a child's
colon was removed, a child may have trouble absorbing enough water. Drinking more
water can help the child to stay hydrated, which may help ease constipation.

 Encourage physical activity. Daily aerobic activity helps promote regular bowel
movements.

 Laxatives. If a child does not respond to or can't tolerate increased fiber, water or physical
activity, certain laxatives — medications to encourage bowel movements — might help
relieve constipation. Ask the doctor whether you should give the child laxatives and about
the risks and benefits.
Nursing management:-

Sr.No. Nursing management

1. Assess the level of pain .
2. Assess fluid and electrolyte imbalance in the patient.
3. Assess the risk of infection.
4. Assess the sleeping pattern of the patient

Nursing diagnosis:-
1. Acute pain related to surgical procedure.
2. Risk of fluid volume deficit related to post operative bleeding .
3. Risk for infection related to surgical procedure.
4. Disturbed sleeping pattern related to disease condition or due to hospital environment.