Case Study Liver Cirrhosis

Capitol University
College of Nursing
SY: 2020 - 2021
A CASE STUDY ON LIVER CIRRHOSIS SECONDARY TO NON-ALCOHOLIC FATTY

LIVER DISEASE, CHOLEDOCHOLITHIASIS
Submitted to:
Mr. Josileo G. Bonzo, RN

Clinical Instructor
2nd Rotation
Submitted by:
Aca, Bulawan O.
Amora, Dimple Jasmine
Andoy, Marylit B.
Barbac, Hannah
Burgos, Kate Aenyle A.
Canda, Joseph Emmanuel
Carlos, James Rafael
April 2023
ABSTRACT
This is a case study of a 69-year-old woman is a known of Non-Alcoholic Fatty
Liver Disease (NAFLD) progressing to Liver Cirrhosis that was admitted at Northern
Mindanao Medical Center. A comprehensive assessment was done in order to create a
vision of the disease process. From risk factors, etiology, and pathophysiology of the
diseases was vigorously being formulated to determine the cause of the disease.
Diagnostic and laboratory evaluations were carefully studied as significant to the disease
process and drug study which provide information of the medications. Importantly,
emphasizing gerontology nursing and establishing nursing care for the patient were built
through this study. A pragmatic Nursing Care Plan was formed in accordance with the
immediate health needs of the patients.
The researchers were able to identify the key contributors to the present status by
understanding the pathophysiology of the disease. From this, both appropriate medical
and nursing intervention were derived. This study contributes to the nursing profession
both in the clinical area and the academe. Management of patients with Liver Cirrhosis
secondary to Non-Alcoholic Fatty Liver Disease with and some similar conditions of liver
problems can still be improved.
Keywords: Non-Alcoholic Fatty Liver Disease, Liver Cirrhosis, Ascites, Abdominal girth,
Peritoneal Dialysis, Diuretics
TABLE OF CONTENTS
ABSTRACT .................................................................................................................... 2
ACKNOWLEDGEMENT ................................................................................................. 4
I. INTRODUCTION .......................................................................................................... 6
Background of the study
Objective of the Study
The significance of the case study in relation to the theme
Scope and limitations of the study
II. PATIENT'S PROFILE ............................................................................................... 10
Demographic Data
Nursing Health History
Vital Signs
Physical Assessment
Anatomical Model
Patient's Developmental Stage
III. THEORETICAL AND CONCEPTUAL FRAMEWORK ............................................ 25
IV. ANATOMY AND PHYSIOLOGY ............................................................................. 26
V. DIAGNOSTIC AND LABORATORY TESTS ............................................................ 28
VI. PATHOPHYSIOLOGY............................................................................................. 38
VII. MEDICAL AND SURGICAL MANAGEMENT ........................................................ 41
Ideal
Actual
Drug Study
VIII. NURSING MANAGEMENT……………………………….…………………………….54
IX. DISCHARGE PLAN……………………………………………………………………….60
X. RESULTS AND DISCUSSION…………………………………………………………...62
XI. CONCLUSION……………………………………………………………………………..63
XII. REFERENCES………………………………………………………………...………….64
ACKNOWLEDGEMENT
The group would like to extend their deep gratitude to the following people who
played an important role in the success and completion of this case study:
First of all, to our Almighty God for giving us wisdom, knowledge, guidance, love,
and strength that really helped the group throughout the process of making our study.
Despite the challenges and hardships that the group faced, He still gives us the light that
we will be able to finish this study with success.
To the group’s clinical instructor, Mr. Josileo Bonzo, RN, for his guidance,
understanding, and patience and for sharing his knowledge with the group so the group
can learn in this field of study.
To our Dean, Dr. Fidela B. Ansale, RN, MAN, for her continuous reminder and
for her full support to her students that inspire us to be more focused and give our all in
making our case study.
To the staff of Northern Mindanao Medical Center Medical Ward for helping us
to achieve our goals for the improvement of this case study by giving us help and a
positive approach.
The group offers the success and completion of our case presentation to these
people. Without them, we will not be enlightened to complete this study.
I. INTRODUCTION
Background of the Study
Patient X is a 69-year-old female, who was admitted at Northern Mindanao Medical

Center last March 31, 2023 with chief complained of abdominal distention as the reason
for hospitalization. She was later diagnosed of having Liver cirrhosis secondary to non-
alcoholic fatty liver disease.
Non-alcoholic fatty liver disease (NAFLD) is a chronic liver disease that is caused
by the accumulation of fat in the liver. The treatment of NAFLD involves managing the
underlying causes of the disease, such as obesity, metabolic syndrome, type 2 diabetes,
and high blood pressure. The main medical knowledge and techniques used in treating
NAFLD include lifestyle modifications, such as weight loss, regular exercise, and dietary
changes, are important in managing NAFLD.
Non-alcoholic fatty liver disease (NAFLD) is becoming a leading cause of liver

cirrhosis worldwide, and there is currently significant research being conducted to better
understand the disease and develop effective treatments. Some of the current
developments in the world related to liver cirrhosis secondary to NAFLD include research
into new treatments: There is ongoing research to develop new treatments for NAFLD
and liver cirrhosis. Some potential treatments being studied include medications to reduce
liver fat, anti-inflammatory drugs, and agents that target fibrosis. Overall, there is
significant progress being made in understanding and addressing liver cirrhosis
secondary to NAFLD. However, more research and awareness is needed to effectively
manage and prevent the disease.
The group decided to choose this case as one of the unusual terms for a lay
person, thus it is rarely encountered in the ward by a student nurse. Acquisition of
cognitive knowledge regarding the topic would enable the researchers in providing
optimum care for clients suffering and in delivering appropriate intervention that would
promote health and wellness for the client. The group gathered up researchers about
Liver Cirrhosis secondary to non-alcoholic fatty liver disease to bring knowledge about
the signs and symptoms, diagnostic test and management of the said disease. This will
serve as a guiding tool in proper management of disease.
Objective of the Study
This case study is aimed at exploring the disease process, and the medical-
surgical and nursing management of liver cirrhosis secondary to non-alcoholic fatty liver
disease, choledocholithiasis. At the end of this case study, the researchers will be able to
trace the pathophysiologic process of liver cirrhosis secondary to non-alcoholic fatty liver
disease, choledocholithiasis, integrate its medical-surgical management into the nursing
process, and systematically identify the priority nursing problems to come up with
comprehensively developed care plans and discharge instructions.
Significance of the Study
Nursing Practice
This case study can be used as a tool in nursing practice because it provides
nursing interventions for patients with Liver Cirrhosis secondary to non-alcoholic. This
study can give a good introduction to the disorder so that an established nursing action
can be quickly utilized and through discovering and rediscovering, and trial after trial of
interventions and facilitation of this condition, more advanced nursing management may
be developed. Through this study, important information regarding this illness has been
gathered which will be helpful for the researchers to have an in-depth understanding of
the said disorder. This study will be able to generate information that will give the staff
nurses in the Medical Ward the opportunity to identify the determinants of care in the ward
and able to gain insights into the areas that need refinement.
Nursing Education
This study can be a useful learning guide in nursing education as this can be used
as a reference for future studies regarding Liver Cirrhosis secondary to non-alcoholic liver
disease and related cases. This case study will enable the students to learn how to assess
patients with Live Cirrhosis and be able to provide appropriate nursing care and
management.
The students will learn about the nursing interventions and have an idea of the
rationale behind their actions. They can apply these interventions in a real setting when
they encounter the same or similar condition. In this way, they are acquiring more
knowledge about the disease that they can use to further develop their skills as student
nurses and future nurses. It may open a new door in the practice of getting quality care
and will refine the student’s clinical reasoning and interpersonal skills in the health care
setting. Nursing educators will be the ones to evaluate the clinical areas that need
improvement and be able to produce strategies for having a conducive learning
environment.
Scope and Delimitation

This study focuses on the patient’s diagnosis of liver cirrhosis secondary to non-
alcoholic fatty liver disease, choledocholithiasis, along with its manifestations, and
treatment plans using the resources that the researchers have acquired. This study
includes all information about the patient’s condition and medical-surgical-nursing
management that took place only within the limits of the nursing care instituted by the
group between April 2, 2023 to April 18, 2023.
Definition of Terms
1. Cirrhosis - a condition in which your liver is scarred and permanently damaged.

Scar tissue replaces healthy liver tissue and prevents your liver from working
normally. Scar tissue also partly blocks the flow of blood through your liver. As
cirrhosis gets worse, your liver begins to fail.
2. Peritoneal Dialysis Insertion - Peritoneal dialysis (PD) is a procedure that can be
used by people whose kidneys are no longer working effectively. It does not cure
or treat the underlying kidney disease. It is intended to replace as many functions
of the failing kidneys as possible. The procedure is performed at home and
primarily works to remove excess fluid and waste products from the blood.
3. Therapeutic Paracentesis - refers to the removal of five liters or more of fluid to
reduce intra-abdominal pressure and relieve the associated dyspnea, abdominal
pain, and early satiety.
4. Bariatric and Metabolic Surgery - the most effective and long-lasting treatment for
severe obesity resulting in significant weight loss and the improvement, prevention
or resolution of many related diseases including type 2 diabetes, heart disease,
hypertension, sleep apnea and certain cancers.
II. PATIENT’S PROFILE
Nursing Health History
The following are information about the patient’s health history which most where
it can view the significant events that important from prior to admission and during
hospitalization. It includes their status post operations, medications, health assessments
both from the medical center and the researchers. The researcher thoroughly focuses in
this part which they can view the key contributing factor to the patient health status.
Chief Complaint
In March 31, 2023 the patient sought to the medical center with a chief complain
of abdominal distention.
Biographical Data
Patient X is a sixty-nine-years-old who is female born on 26th of May, 1954.

Currently reside on Cagayan De Oro, Misamis Oriental. She’s a widow for four in a half
years and a retired teacher (teacher for almost 30 years in a public elementary school).
Patient’s pronouns are she/her but the researcher address her as “ma’am”, she’s a
Catholic and a Filipino citizen. The families and relatives somehow helps her in financials
and during hospitalization.
History of Present Illness
Patient X is a known case of liver cirrhosis secondary to non-fatty liver disease

(NAFLD). 6 months prior to admission, patient noted abdominal distention which she did
not sought for any consult first and tolerated the condition. 5 months prior to admission
the patient still noticing her condition then she decide to consult in one of the medical
center (1st hospital) in Cagayan De Oro and being referred again to another medical
center (2nd hospital) as other option for her peritoneal drains and insertion due to financial
issues.
Patient 2 months prior to admission still noticing the abdomen being distended and
now associated with epigastric pain with the pain scale of (8/10). The patient now sought
in the third medical center (3rd hospital) for 5 days. During in interim (intervening period),
the patient noted with abdominal distention where she was advised to be admitted and
for peritoneal catheterization.
Past Health History
Patient X has already admitted in many (she states more than three times) where
she begun aspiration appointments in 1990’s. 2nd hospital where she ask for second
opinion about her condition, she was diagnosed with (1) complicated UTI and (2) hepatic
encephalopathy to consider decompensated liver cirrhosis. The surgical management
being done to the patient there was the paracentesis and thoracentesis. Patient no history
of use illicit drugs and allergies both food and medications. In (COVID-19) pandemic the
patient being vaccinated with 2 Pfizer dose.
Family History
Patient recalls and state that they have no record of or any history of arthritis,
stroke, bleeding, and liver, kidney, heart, or thyroid problems both maternal and paternal
side. No family relative’s use of illicit drug but with smoking children.
Vitals Signs
The initial assessment was done last April 2, 2023. The following vital signs being
assed was: Blood Pressure: 120/60 mmHg (laying on bed), Pulse Rate: 69 bpm,
Respiratory Rate: 16 cpm, Temperature of 37.0 degrees Celsius, 97%, Oral Intake: 1250
ml/day, Urine Output: 1-2x with 240cc/day, Last Bowel Movement: once (1:34 pm), and
her height is over 157 cm with weight of 63 kg.
Physical Assessment
As the first step in the nursing process, comprehensive nursing assessment entails
systematic and consistent data collection to facilitate the creation of a patient-specific
nursing procedure (Khatiban et al., 2019). Jones (2013) states that Marjorie Gordon’s
Function Health Assessment offered functional health patterns as a guide for creating a
comprehensive nursing data base of pertinent client assessment data.
Health perception and health management pattern
Prior to Admission: Patient is positively waiting about the upcoming peritoneal

dialysis (PD) insertion which she stated hoping that if they have the operation here in this
medical center it could also help them in terms of financial and believing that she’s a good
taxpayer in this country she is being prioritize.
During Admission: Patient shows frustration (dissatisfaction arising from

unfulfilled needs) of the doctor’s response about the to schedule PD insertion which she
stated that she waits more than 3 days and still being refer again.
Nutritional-metabolic pattern
Prior to Admission: Patient has strong desire to eat and craves for something.
She stated that only Filipino delicacy and dishes satisfy her day-to-day meals. In her 30’s,
she love to eat some fry foods (fried chicken and fish crackers) especially it is easy to buy
in canteen and a stress reliever. She is not usually drinks water in which only available in
school canteen that time was carbonated soft drinks that are popular in that time.
Restricting herself from drinking alcohol beverages because of her belief.
During Admission: Patient was rejecting the food (egg white) and medication
(Lactulose) due to the smell makes her feel nauseated and she can only tolerate only 3-
4 tablespoons of rice porridge “Lugaw” and she can finish her one bottle (1000ml of water)
a day so that she can’t feel any nauseous.
Elimination pattern
Prior to Admission: Patient notes that she usually can excrete 1-2 times day, it
has no distinct foul odor, clumped sausage like yellowish brownish impacted stool.
Epigastric pain and straining during defecation.
During Admission: Patient are being constipated for past several days of
hospitalization and being prescribed medication to able to defecate. Stool characteristics
was yellowish watery stool. No pain and straining during defecation.
Activity and exercise pattern
Prior to Admission: Patient has no regular stress exercise due to her age.
During Admission: Patient needs an assistance in terms of her hospitalization

and the health care providers also provides some positioning hours in the ward.
ACTIVIES OF DAILY LIVING/ MOBILITY STATUS
PRIOR TO ADMISSION
Feeding 0 Meal 0 Bed Mobility 0
preparation
Bathing 0 Cleaning 0 Chair/ Toliet 0
Transfer
Dressing 0 Laundry 0 Ambulation 0
Grooming 0 Toileting 0 R.O.M 0
DURING ADMISSION
Feeding 2 Meal 2 Bed Mobility 2
preparation
Bathing 2 Cleaning 2 Chair/ Toliet 2
Transfer
Dressing 2 Laundry 4 Ambulation 2
Grooming 2 Toileting 2 R.O.M 2
Legend: 0 – Total Independence
1 – Assist with Device

2 – Assist with Person
3 – Assist with Device and Person
4 – Total Dependence
Sleep and rest pattern
Prior to Admission: Patients X sleep for approximately 6-9 hours per day. She
has slight sleep disturbances especially in laying on bed in flat position she stated that
she felt some like drowning and usually snore.
During Admission: Patient X trouble sleeping during hospitalization because of

the noise and hot temperature of the environment which total number of sleep hours
mostly 4-6 hours in day and doing daytime sleeping.
Cognitive and perceptual pattern
Prior to Admission: Patient X believes due to her age there is some quite
changes of her memory and able to recall but she positively that able to remember some
for in a mean time. Patient is alert and oriented (date, time, and place).
During Admission: Patient X is pausing when being questioned to think which

she is difficult to recall such events. Her level of consciousness have no further changes
since admission.
Self-perception and self-concept pattern
Prior to Admission: Patient experienced disturbed body image due to the

distention of the abdomen and being drastically lose weight.
During Admission: Patient she states that her body is weak and fragile since she
was lose weight because of being hospitalized.
Roles and relationships pattern
Prior to Admission: Patient X is a widow for almost 4 years which mostly she
dependents to her daughter-in-law both for her daily living and financials are being
supported by her.
During Admission: Patient X has been dependent on her daughter-in-law since

hospitalization. Her children and relatives visit her usually in non-working hours or noon
time where they brings food and prayers.
Sexuality and reproduction patterns

Prior to Admission: Patient X has late-onset of menopausal period (LMP last
February 2018). She does not use any contraceptives or birth control. Her sexual
activities changes since becomes a widow.
During Admission: Patient X shows no further reproductive problems. In

urination, patient usually urinate about 3-4 per day because she drinks a lot of water
during hospitalization.
Coping and stress tolerance pattern
Prior to Admission: Patient able to cope up any certain problems by doing such
pacing and able to release stress through having a conversation to her families and
relatives.
During Admission: Patient can’t focus due to the environment and being stress
about her upcoming procedures.
Value- belief pattern
Patient X and family predominantly are Roman Catholic, when her children arrive
in the hospital they usual have 3 o’clock prayer ( which usually her children arrived) and
some foods and drinks are being restrict to the patient (alcoholic beverages) and even
smoking.
Health/Physical Assessment
Patient physical assessment starts on 3rd, 4th, 5th, 10th, and 17th of April, 2023
located at Northern Mindanao Medical Center (NMMC) – TRANSIENT ward #3. The
followings includes the general health survey, vital signs, and head-to-toe assessment
(review systems)
General Health Survey
• Integumentary System
- The patient’s skin has yellowish appearance (jaundice), the texture was
quietly rough. The skin turgor is firm, dry, and cool to touch. Wrinkles in
face and both extremities, striated abdomen, and has long yellowed and
opaque clean nails. The hair fine and evenly distributed with no any
signs of infestation.
• Head, Eyes, Ears, Nose, and Throat (HEENT)
- The patient’s the head is in normocephalic and facial movements is
symmetrical. Fontanels are closed and no any further headaches
occurs.
- Eye lids are symmetrical but the periorbital regions is sunken and
discoloration noted. Conjunctiva is pale, cornea/lens is both eyes are
opacity, sclera is ecteric, and pupil’s size is 6 mm. Both eyes are
reactive to light (+) to brisk, uniform in constriction, and visual acuity and
peripheral vision genuinely decrease.
- External pinnae are normoset, no discharges noted in external canal.
No cerumen impacted and tympanic membrane is intact. Gross hearing
slight decreased.
- Nose in alar flaring, septum is in midline, mucosa is pinkish and no
discharges, and both patent.
- Lips are dry and crack-like appearance, mucosa is pinkish. Tongue is in
midline with missing teeth and carries, gums is quite pale.
- Throat or The pharynx is in midline and pinkish color and thyroids are
not palpable or tenderness not present (no inflammation of the
posterior).
• Respiratory System
- The breathing pattern is normal (eupnea) but with some exertion
especially in flat position, no signs use of accessory muscle. Anterior-
Posterior/ Lateral of Chest: 1:2 ratio. Lung expansion and Tactile
Fremitus is symmetrical. No signs of cough, rhonchi, pleural friction rub
(grating sounds-like).
- Day 1 of assessment (April 3, 2023): patient has respiratory rate of 16
cpm and oxygen saturation of 97%, she experience orthopnea and sleep
usually with two pillow underneath on her head.
cpm and oxygen saturation of 97%, experience orthopnea and sleep
cpm and oxygen saturation of 97%, experience orthopnea and sleep
- Day 4 of assessment (April 11, 2023): patient has respiratory rate of
22 cpm and oxygen saturation of 97%, no signs of orthopnea and can
tolerate resting in supine position.
- Day 5 of assessment (April 17, 2023): patient has respiratory rate of
19 cpm and oxygen saturation of 97%, no signs of orthopnea and can
tolerate resting in supine position.
• Cardiovascular System
- No signs of chest pain, no distended jugular veins, and precordial area
is flat. Arterial Impulse is distinct with apical rate & rhythm of 60 bpm.
Heart sound is regular, no murmur. Peripheral pulses is weak and faint
during palpation. Capillary refill time is <2 seconds.
• Gastrointestinal System
- Day 1 to 3 of assessment (April 3 to April 5, 2023): Striated abdomen
(stretch marks) is present, the configuration is distended in globular-like.
No distinct sound noted (absent bowel sounds), positive for shifting
dullness and fluid-wave test.
- Day 1 of assessment (April 3, 2023): abdominal girth of 97.3 cm.
Patient is anorexic due to the smell of food and medication. She defecate
with yellowish watery stool.
Patient is anorexic due to the smell of food and medication She defecate
with yellowish brownish impacted stool
Patient is anorexic due to the smell of food and medication. She defecate
with yellowish brownish impacted stool
- Day 4 of assessment (April 11, 2023): abdominal girth of 100.5 cm. She
defecate with clay-colored impacted stool
- Day 5 of assessment (April 17, 2023): abdominal girth of 93.1 cm. She
defecate with clay-colored impacted stool. Loose skin noted with no signs
of shifting dullness, palpable spleen and liver.
• Genitourinary System
- Day 1 of assessment (April 3, 2023): in urination, patient in diaper used
with 240cc/day, which means patient is in anuric state (2 times from that
day)
- Day 2 of assessment (April 4, 2023): in urination, patient in diaper used
with 240cc/day, which means patient is in polyuric state (2- 3 times from
that day)
- Day 3 of assessment (April 5, 2023): in urination, patient able to go to
restroom with assist of person with 200cc/ day, which patient is polyuric
state (3-4 times from that day)
restroom with assist of person with 200cc (3-4 times from that day)
restroom with assist of person with 200cc/ day (4 times from that day)
• Reproductive System
- Day 1 to 5 of assessment (April 3 to April 17, 2023): Labia are
asymmetrical, no nodules, tenderness, pain during the assessment.
Breast are unequal and nipple are retracted with o any sign of mass,
nodules, or tenderness.
• Musculoskeletal System
- Day 1 to 3 of assessment (April 3 to April 5, 2023): Patient’s range of
motion is decreased due to the abdominal distention. Patient needs
assist to be sitting position and any ADL/ambulation. Both muscle tone
and strength are weak with uncoordinated gait. Non-pitting, no
tenderness bipedal edema both lower extremities.
- Day 4 of assessment (April 11, 2023): Patient’s range of motion is
decreased due to the abdominal distention. Patient needs assist to
be sitting position and any ADL/ambulation. Bipedal edema is
decreasing.
- Day 5 of assessment (April 17, 2023): Patient’s range of motion is
decreased due to the abdominal distention. Patient needs assist to
be sitting position and any ADL/ambulation. Bipedal edema are not
fully be distinct and patient no further complains.
• Neurological System
- Day 1 to 5 of assessment (April 1 to April 17, 2023): Patient X is
conscious and coherent, oriented and slight restless because of external
environment. Other appropriate behavior/communication: low pitch, soft
voice, staggering and not mostly audible.
ANATOMICAL MODEL
Day 1 of Assessment (April 3, 2023)
HEENT:
Neurological: (+) changes of (+)ICTERIC
sensorium due to sign of aging
Conjunctiva: pale
-Staggering, not audible sounds
or voice Cornea/lens: opacity
Missing teeth and carries
Respiratory: (+) orthopnea

-Respiratory rate of 16 cpm
Cardiovascular: HR 69 bpm,
no murmur, no chest pain
Integumentary:
-Jaundice
Gastrointestinal:
Abdominal distention
IV THERAPY: (+) shifting dullness
IV HEPLOCK in right arm Abdominal girth: 97.3 cm.
Stool: yellowish watery

Genitourinary: Anorexic
240cc/day, which means patient
is in anuric state (2 from that day Reproductive:
diaper used)
No nodules, tenderness, pain
Musculoskeletal:
ROM decreased
Uncoordinated gait (with assist

of person)
Non-pitting bipedal edema

HEENT:
Conjunctiva: pale

-Respiratory rate of 21 cpm no murmur, no chest pain
Integumentary:
Gastrointestinal:
-Jaundice
(+) shifting dullness

IV THERAPY: Abdominal girth: 100.3 cm.
IV HEPLOCK in right arm Stool: yellowish watery
Anorexic
Genitourinary:
240cc/day, which means patient Reproductive:
is in polyuric state (2- 3 times
from that day)
Musculoskeletal:
ROM decreased

of person)

HEENT:
Conjunctiva: pale

Integumentary:
Gastrointestinal:
-Jaundice
(+) shifting dullness

IV THERAPY: Abdominal girth: 104.5 cm.
IV HEPLOCK in right arm Stool: yellowish watery
Anorexic
Genitourinary:
200cc/ day, which patient is Reproductive:
polyuric state (3-4 times from
that day)
Musculoskeletal:
ROM decreased

of person)

HEENT:
Conjunctiva: pale
Respiratory:
Integumentary:
Gastrointestinal:
-Jaundice
Abdominal girth: 100.5 cm.

IV THERAPY: Stool: clay-colored impacted
IV HEPLOCK in right arm
Genitourinary: Reproductive:
200cc (3-4 times from that day)
Musculoskeletal:
ROM decreased

of person)
Bipedal edema noted

HEENT:
Conjunctiva: pale

Integumentary:
Gastrointestinal:
-Jaundice
Loose skin turgor (abdomen)
Abdominal girth: 93.1 cm.
IV THERAPY: Stool: clay-colored impacted
IV HEPLOCK in right arm
Genitourinary: Reproductive:
200cc (4 times from that day)
Musculoskeletal:
ROM decreased
Uncoordinated gait (with

assist of person)
Vital Signs: Diagram (April, 2023)
Day Vital Signs Intake Output
BP HR RR TEMP O2 SAT IV ORAL URINE STOOL
st
1 day of 120/60 69 bpm 16 cpm 37.0 °C 97% HEPLOCK 1250 mL 800 1
assessment mmHg
(3:00 pm)
2nd day of 110/70 77 bpm 21 cpm 36.8 °C 98% HEPLOCK 1000 mL 720 2
assessment mmHg
(2-10:00 pm)
3rd day of 100/60 66 bpm 23 cpm 37.0 °C 97% HEPLOCK 500 mL 840 2
assessment mmHg
(2-10:00 pm)
4th day of 100/60 78 bpm 22 cpm 35.8 °C 98% HEPLOCK 500 mL 800 1
assessment mmHg
(5:00 pm)
5TH day of 90/60 73 bpm 19 cpm 36.5 °C 98% HEPLOCK 750 800 2
assessment mmHg
(3:00 pm)
Patient's Developmental Stage
Erik-Erikson’s Psychosocial Development
• Integrity vs. Despair. It may become necessary for an elderly person to consider
and evaluate what they have acquired throughout their lifetime in order to
determine what their heirs will receive upon their death (van der Kaap-Deeder et
al., 2021).
Positive outcome: Patient X accepts some changes in her memories which the time her
husband died was so painful to her but many years to come her vulnerability becomes
one of his strength to cope certain events. She has no regrets in life especially being a
teacher for almost 30 years she states that helping so many children through learning is
like you build a good foundation for their future. In her children she was happy because
they are still with her through this day on and even her students who do remember her.
Negative outcome: Patient somehow felt unfulfilled due to lack of healthy lifestyle, she
regrets in ways that if she has good coping mechanism she will not putting the food as
stress reliever.
Jean Piaget's Stages of Cognitive Development
• Formal Operational. The capacity to think abstractly or to consider possibilities

and concepts regarding circumstances that have never been directly experienced
is a hallmark of this type of thinking (Cherry, 2023).
The patient is able to think logically about herself since the prior for admission, in the
1st hospital they went is the procedure was quite expensive since they still recover from
her husband death she decide that she will go treatment for an public hospital where less
cost and she’s also a good taxpayer. She thought that being in a public hospital going for
a treatment especially about this operation could easily be prioritize but during the
admission she still questioning the doctors why her operation still being schedule where
she shows frustration for the doctors.
Lawrence Kohlberg's Stages of Moral Development
• Universal Principles of Ethics. Equity, nobility, and regard are thoughts that
structure the premise of widespread standards. Regulations and rules are just
viable assuming that they support the general standards, which every individual at
this stage attempts to maintain (Ma, 2013).
23
The patient still considerate and being respectful to the health care provider even
though her stress cannot handle such events, she states that she feels how to be a worker
in a government where everything should be pays in sweat and tears. As the doctors
informs them again to being refer (3rd time) she now feels regrets from what the result of
their admission, during in the interview she states somehow she believe someone is more
in need for medical attention and she knew that the nurses and doctors keep on tracking
us and monitoring our health status.
24
III. THEORETICAL AND CONCEPTUAL FRAMEWORK
The Interpersonal Relations Theory by Hildegard Peplau fits the case of patient X
well as it is emphasized the need for a partnership between nurse and patient as opposed
to the patient passively receiving treatment and the nurse passively acting out doctor’s
orders (Gonzalo, 2023). The theory assumes that (1) Nurse and the patient can interact.
(2) Both the patient and nurse mature as the result of the therapeutic interaction. (3)
Communication and interviewing skills remain fundamental nursing tools. And lastly, (4)
Peplau believed that nurses must clearly understand themselves to promote their client’s
growth and avoid limiting their choices to those that nurses value (Gonzalo, 2023). As our
patient develops anxiety during hospitalization, this theory helps the overall physical and
emotional state that give her a strength to fight the disease.
25
IV. ANATOMY AND PHYSIOLOGY
The digestive system is responsible for breaking down the food into fats, proteins,
and carbohydrates to smaller parts. The food that was broken down will be absorbed into
the bloodstream and the nutrients will be carried throughout the cell in the body. It includes
the mouth, esophagus, small intestine, large intestine, anus, liver, gallbladder, pancreas,
and spleen.
The liver is in the upper quadrant of the abdomen; it is divided into two lobes, right
and left. The liver weighs about 3 pounds and it is a dark reddish-brown organ. The liver
is responsible for metabolism and energy production; it is the one who filtered and remove
toxins from the blood. Due to consuming too many calories, obesity, and inactivity in
lifestyle, the fats were built up in the liver and caused serious complicated liver damage
organ. he liver is located in the upper right-hand portion of the abdominal cavity, beneath
the diaphragm, and on top of the stomach, right kidney, and intestines.
Shaped like a cone, the liver is a dark reddish-brown organ that weighs about 3
pounds. There are 2 distinct sources that supply blood to the liver, including the following:
• Oxygenated blood flows in from the hepatic artery
• Nutrient-rich blood flows in from the hepatic portal vein
The liver holds about one pint (13%) of the body's blood supply at any given
moment. The liver consists of 2 main lobes. Both are made up of 8 segments that consist
of 1,000 lobules (small lobes). These lobules are connected to small ducts (tubes) that
connect with larger ducts to form the common hepatic duct. The common hepatic duct
transports the bile made by the liver cells to the gallbladder and duodenum (the first part
of the small intestine) via the common bile duct. The liver regulates most chemical levels
in the blood and excretes a product called bile. This helps carry away waste products
from the liver. All the blood leaving the stomach and intestines passes through the liver.
The liver processes this blood and breaks down, balances, and creates the nutrients and
also metabolizes drugs into forms that are easier to use for the rest of the body or that
are nontoxic. More than 500 vital functions have been identified with the liver. Some of
the more well-known functions include the following:
• Production of bile, which helps carry away waste and break down fats in the small
intestine during digestion
• Production of certain proteins for blood plasma
• Production of cholesterol and special proteins to help carry fats through the body
26
• Conversion of excess glucose into glycogen for storage (glycogen can later be
converted back to glucose for energy) and to balance and make glucose as
needed
• Regulation of blood levels of amino acids, which form the building blocks of
proteins
• Processing of hemoglobin for use of its iron content (the liver stores iron)
• Conversion of poisonous ammonia to urea (urea is an end product of protein

metabolism and is excreted in the urine)
• Clearing the blood of drugs and other poisonous substances
• Regulating blood clotting
• Resisting infections by making immune factors and removing bacteria from the
bloodstream
• Clearance of bilirubin, also from red blood cells. If there is an accumulation of

bilirubin, the skin and eyes turn yellow.
When the liver has broken down harmful substances, its by-products are excreted
into the bile or blood. Bile by-products enter the intestine and leave the body in the form
of feces. Blood by-products are filtered out by the kidneys, and leave the body in the form
of urine.
The gallbladder is responsible for storing bile from the liver then it is released to
the small intestine where it will help to break down the fats from digested food. As a result
of late-stage liver diseases, it can slow the bile from flowing smoothly to the gallbladder
and cause the bile to harden into gallstones due to the cholesterol-supersaturated bile.
The spleen’s key role is to fight invading germs and gets rid of damaged blood
cells. It also produces antibodies that help to protect our body from any infection. Liver
cirrhosis can obstruct the blood flow to the liver which the spleen becomes filled with
blood leading to splenomegaly.
The common bile duct functions as carrying the bile from the gallbladder to the
pancreas and into the small intestine. Due to obstruction of bile flow to the common bile
duct, there was inflammation in the bile duct, and jaundice was developed due to
increasing levels of bilirubin; high bilirubin indicates liver damage.
27
V. ACTUAL LABORATORY AND DIAGNOSTIC TESTS
ULTRASOUND – ABDOMEN, WHOLE (March 03, 2023)

Clinical Information: Liver Cirrhosis
Procedure: Ultrasound of the Whole Abdomen
Comparison: None
Findings:
The liver is normal in size with heterogenous parenchymal echogenicity. The borders are
irregular and nodular. No focal mass seen. The bile ducts are not dilated. Vascular
structures are normal.
Gallbladder is physiologically distended measuring 6.6 x 2.6 cm. There are at least two
intraluminal hyperechoic shadowing foci within the gall bladder measuring 0.6 and 1.2 cm
in diameter. Its wall is thickened, measuring 0.5 cm.
Spleen is enlarged measuring 12.6 cm craniocaudally with homogenous parenchymal

echogenicity.
The pancreas is unremarkable. No focal mass lesion is seen.
The aorta is patent with no abnormal dilatation.
RIGHT KIDNEY: 9.0 X 4.7 X 4.4 cm cortical thickness of 0.7 cm.

LEFT KIDNEY: 9.1 x 4.2 x 4.4 cm with cortical thickness of 0.9 cm.
Uterus is anteverted measuring 3.2 x 2.8 x 2.5 cm and shows homogenous myometrial
echo pattern. Endometrial stripe is echogenic measuring 2 mm. Cervix intact. Ovaries are
not visualized. No adnexal mass is seen.
Free fluid is seen in all quadrants of the abdomen.
IMPRESSION:
LIVER CIRRHOSIS
CHOLELITHIASIS WITH CHOLECYSTITIS
SPLENOMEGALY
MINIMAL TO MODERATE ASCITES
ANTEVERTED UTERUS WITH THIN ENDOMETRIUM
SONOGRAPHICALLY NORMAL PANCREAS, KIDNEYS, AND URINARY BLADDER
Implications:
The result shows that the patient has (1) Liver cirrhosis – a condition in which your liver
is scarred and permanently damaged. Scar tissue replaces healthy liver tissue and
prevents your liver from working normally. (2) Cholelithiasis – hardened deposits of
digestive fluid that can form in your gallbladder. (3) Splenomegaly – enlargement of the
spleen measured by size or weight. The spleen plays a significant role in hematopoiesis
and immunosurveillance. (4) Minimal to moderate ascites – a condition in which fluid
collects in spaces within your abdomen. As fluid collects in the abdomen, it can affect
your lungs, kidneys, and other organs. Ascites causes abdominal pain, swelling, nausea,
vomiting, and other difficulties.
28
COMPLETE BLOOD COUNT (March 31, 2023)
Test Result Unit Reference Interpretation Indication
White blood 7.38 x10^3/uL 5.0-10.0 NORMAL Normal amount

cell of WBC
Red blood cell 2.86 x10^6/uL 4.2-5.4 BELOW NORMAL May indicate
hemolysis.
Hemolysis is
triggered by
portosystemic
shunting and
splenomegaly.
Hemoglobin 10.40 g/Dl 11.7.-14.5 BELOW NORMAL May indicate

iron deficiency
and anemia
Hematocrit 29.20 % 34.1-44.3 BELOW NORMAL Indicates

infection or
WBC disorder
such as anemia
MCV 102.10 Fl 80.0-96.0 ABOVE NORMAL The RBC are

too large and
indicates
macrocytic
anemia
MCH 36.40 Pg 27.0-31.0 ABOVE NORMAL Indication for

macrocytic
anemia
MCHC 35.60 g/dL 31.5-35.0 ABOVE NORMAL Higher than

normal
concentration of
hemoglobin in
the red blood
cells.
RDW 16.20 % 10.0-15.0 ABOVE NORMAL May indicate

nutrient
deficiency of
iron
MPV 11.00 fL 8.0-12.0 NORMAL Average size if

platelets found
in blood
29
PDW 11.10 fL 8.0-12.0 NORMAL Platelets that
are mostly the
same size
Differential
Count
Lymphocyte 18.30 % 18-45 NORMAL Within normal

range
Neutrophil 67.90 % 43.4-76.2 NORMAL Within normal

range
Basophil 0.40 % 1.0-3.0 BELOW NORMAL Basopenia

could be the
result of the
basophils
working
overtime to
treat an
infection that is
taking longer
than normal to
heal. Fatty liver
is associated
with recurrent
bacterial
infection.
Monocytes 9.60 % 4-8 ABOVE NORMAL Monocytosis

happens when
your monocyte
count is too
high.
Monocytosis is
often linked to
infectious
diseases.
Eosinophil 3.80 % 2-4 NORMAL Within normal

range
Platelet count 210 x10^3/uL 150-400 NORMAL Platelet count in

the blood is
normal.
BLOOD CHEMISTRY RESULT FORM (March 31, 2023)

Results Reference Values
Blood Urea Nitrogen = (H) 28.3 mg/dl 8.4 – 25.7mg/dl
Creatinine = 1.43 mg/dl 0.6 – 1.8mg/dl
Electrolytes:
Potassium = 3.64 mmol/L 3.5 – 5.3mmol/L
Sodium = 137.1 mmol/L 135-148mmol/L
Ionized Calcium = 1.25 mmol/L 1.12 – 1.23mmol/L
30
Implications:
A blood urea nitrogen (BUN) test can reveal important information about the kidney's
health. The BUN test measures the blood's level of urea nitrogen (MedlinePlus, 2022).
The kidneys eliminate a waste product from the blood called urea nitrogen (MedlinePlus,
2022). The patient’s BUN levels are elevated and levels that are higher than usual may
indicate that the kidneys aren't functioning properly (MedlinePlus, 2022).
One of the indicators of kidney function is creatinine. Creatinine is a waste product that
results from the body's muscles going through natural wear and tear (National Kidney
Foundation, 2016). Age and physical size can affect the blood's level of creatinine
(National Kidney Foundation, 2016). An early indication that the kidneys are not
functioning properly may be a creatinine level that is higher than 1.2 for women and
greater than 1.4 for men (National Kidney Foundation, 2016). Although the patient’s
creatinine is still within normal, its level is already alarming, it could be an early sign of
kidney problems since creatinine levels in the blood rise as kidney damage worsens
(National Kidney Foundation, 2016).
BLOOD CHEMISTRY RESULT FORM (MARCH 31, 2023)

Liver Profile: Results Reference Values
S.G.O.T/AST = (H) 54.6 U/L 0-31U/L
S.G.P.T/ ALT = 20. 0 U/L 0-32U/L
Bilirubin:
Total = (H) 4.71 mg/dL 3.5 – 5.0mg/dL
Direct = (H) 2.6 mg/dl 0.00-0.25mg/dl
Indirect = (H) 2.1 mg/dl 0-1.0
Implications:
Aspartate aminotransferase (AST) and alanine transaminase (ALT) are liver and
muscle enzymes, AST is found in the liver, brain, pancreas, heart, kidneys, lungs, and
skeletal muscles (Daniel, 2022). ALT is found mainly in the liver. ALT helps in converting
proteins into energy for the liver cells and AST helps metabolize amino acids (Mayo Clinic,
2021). Although AST is normally present in blood (Mayo Clinic, 2021), it must be in low
level. A high AST with a normal ALT may mean that the problem is coming from a different
part of the body but still this could indicate a problem in the liver.
On the patient’s liver profile, the ALT is within normal range, but the AST is highly
elevated this could indicate that the problem is much more likely due to a condition of the
heart, muscle, kidney, or destruction of red blood cells (hemolysis) rather than the liver
(Burk & Rossiaky, 2021) this supports why the red blood cells of the patient is below
normal on the complete blood count test.
The AST/ALT ratio is used to explain the connection between these enzymes. This
computation compares your blood's AST and ALT concentrations (Daniel, 2022).
Depending on the value that is raised and the amount of elevation. An AST/ALT ratio
higher than one (where the AST is higher than ALT) means the patient may have cirrhosis
(Daniel, 2022).
31
The amount of bilirubin in your blood is determined via a bilirubin test. The result
shows elevated direct and indirect bilirubin (Lee at al., 2021). Direct bilirubin (DB) levels
rise in liver cirrhosis because of portal flow distortion, intrahepatic cholestasis, and
impaired hepatic bilirubin clearance (Lee at al., 2021). Meanwhile, hemolysis is triggered
by portosystemic shunting and splenomegaly, which raises the level of indirect bilirubin
(Lee at al., 2021).
PROTHROMBIN TIME (MARCH 31, 2023)

PROTIME: 20.4 .
(N.R. 11.0 – 16.0 secs)
CONTROL: 12.8 .
THERAPEUTIC RANGE: 0-70
I.N.R 1.59 .
Prothrombin time (PT) measures how many seconds it takes for your blood to clot (Dreis,
2023). The patient’s protime is elevated, this usually happens because the liver is not
making the right amount of blood clotting proteins, so the clotting process takes longer
(Veterans Affair, 2023). A high PT usually means that there is serious liver damage or
cirrhosis (Veterans Affair, 2023).
International normalized ratio (INR) this number is calculated from PT (Dreis, 2023). The
INR gives information about how quickly your blood clots when compared to blood that
clots normally (Veterans Affair, 2023). A normal INR is 1.1. Each increase of 0.1 means
the blood is slightly thinner (Veterans Affair, 2023). INR is related to the PT (Veterans
Affair, 2023). If there is serious liver disease and cirrhosis, the liver may not produce the
proper number of proteins and then the blood is not able to clot as it should (Veterans
Affair, 2023).
COMPLETE BLOOD COUNT (APRIL 02, 2023)
Test Result Unit Reference Interpretation Indication

cell of WBC
Red blood cell 2.64 x10^6/uL 4.2-5.4 BELOW NORMAL May indicate
hemolysis.
Hemolysis is
triggered by
portosystemic
shunting and
splenomegaly.
Hemoglobin 9.70 g/Dl 11.7.-14.5 BELOW NORMAL May indicate

iron deficiency
and anemia
Hematocrit 26.80 % 34.1-44.3 BELOW NORMAL Indicates

infection or
WBC disorder
such as anemia
32
MCV 101.50 Fl 80.0-96.0 ABOVE NORMAL The RBC are
too large and
indicates
macrocytic
anemia
MCH 36.70 Pg 27.0-31.0 ABOVE NORMAL Indication for

macrocytic
anemia
MCHC 36.20 g/dL 31.5-35.0 ABOVE NORMAL Higher than

normal
concentration of
hemoglobin in
the red blood
cells.
RDW 16.10 % 10.0-15.0 ABOVE NORMAL May indicate

nutrient
deficiency of
iron

platelets found
in blood
PDW 10.40 fL 8.0-12.0 NORMAL Platelets that

are mostly the
same size
Differential
Count

range

range
Basophil 0.60 % 1.0-3.0 BELOW NORMAL Basopenia

could be the
result of the
basophils
working
overtime to
treat an
infection that is
taking longer
than normal to
heal. Fatty liver
is associated
with recurrent
bacterial
infection.
Monocytes 10.10 % 4-8 ABOVE NORMAL Monocytosis

happens when
your monocyte
count is too
high.
33
Monocytosis is
often linked to
infectious
diseases.

range
Platelet count 149 x10^3/uL 150-400 BELOW NORMAL Platelet count in

the blood is
below normal
thus the patient
is at risk for
bleeding
BLOOD CHEMISTRY RESULT FORM (APRIL 02, 2023)

Bilirubin: Results Reference Values
Albumin = (L) 3.00 g/dL 3.5 – 5.0g/dL
Implication:
Albumin is a protein made by your liver (MedlinePlus, 2022). Albumin enters the
bloodstream and plays a role in preventing fluid from seeping into other tissues from the
blood vessels (MedlinePlus, 2022) The patient’s albumin is low thus could be the
reason why the patient had a manifestation of massive ascites.
COMPLETE BLOOD COUNT (APRIL 04, 2023)
Test Result Unit Reference Interpretation Implication

cell of WBC
Red blood cell 2.62 x10^6/uL 4.2-5.4 BELOW May indicate

NORMAL hemolysis.
Hemolysis is
triggered by
portosystemic
shunting and
splenomegaly.
34
Hemoglobin 9.60 g/Dl 11.7.-14.5 BELOW May indicate
NORMAL iron deficiency
and anemia
Hematocrit 26.80 % 34.1-44.3 BELOW Indicates

NORMAL infection or
WBC disorder
such as anemia
MCV 102.30 Fl 80.0-96.0 ABOVE The RBC are too

NORMAL large and
indicates
macrocytic
anemia
MCH 36.60 Pg 27.0-31.0 ABOVE Indication for

NORMAL macrocytic
anemia
MCHC 35.80 g/dL 31.5-35.0 SLIGHTLY Higher than

ABOVE normal
NORMAL concentration of
hemoglobin in
the red blood
cells.
RDW 16.10 % 10.0-15.0 ABOVE May indicate

NORMAL nutrient
deficiency of
iron

platelets found
in blood
PDW 10.40 fL 8.0-12.0 NORMAL Indicates

platelets that
are mostly the
same size
Differential
Count

range

range
Basophil 4.00 % 1.0-3.0 ABOVE An abnormally

NORMAL high basophil
level is called
basophilia. It
can be a sign of
chronic
inflammation in
your body.
35
Monocytes 10.70 % 4-8 ABOVE High monocyte
NORMAL count may
indicate
infections

range
Platelet count 152 x10^3/uL 150-400 NORMAL Within normal

range
BLOOD CHEMISTRY RESULT FORM (APRIL 04, 2023)

Liver Profile: Results Reference Values
S.G.O.T/AST = (H) 54.6 U/L 0-31U/L
S.G.P.T/ ALT = 20. 0 U/L 0-32U/L
Bilirubin:
Total = (H) 4.71 mg/dL 3.5 – 5.0mg/dL
Direct = (H) 2.6 mg/dl 0.00-0.25mg/dl
Indirect = (H) 2.1 mg/dl 0-1.0
Implications:
Aspartate aminotransferase (AST) and alanine transaminase (ALT) are liver and
muscle enzymes, AST is found in the liver, brain, pancreas, heart, kidneys, lungs, and
skeletal muscles (Daniel, 2022). ALT is found mainly in the liver. ALT helps in converting
proteins into energy for the liver cells and AST helps metabolize amino acids (Mayo Clinic,
2021). Although AST is normally present in blood (Mayo Clinic, 2021), it must be in low
level. A high AST with a normal ALT may mean that the problem is coming from a different
part of the body but still this could indicate a problem in the liver.
On the patient’s liver profile, the ALT is within normal range, but the AST is highly
elevated this could indicate that the problem is much more likely due to a condition of the
heart, muscle, kidney, or destruction of red blood cells (hemolysis) rather than the liver
(Burk & Rossiaky, 2021) this supports why the red blood cells of the patient is below
normal on the complete blood count test.
The AST/ALT ratio is used to explain the connection between these enzymes. This
computation compares your blood's AST and ALT concentrations (Daniel, 2022).
Depending on the value that is raised and the amount of elevation. An AST/ALT ratio
higher than one (where the AST is higher than ALT) means the patient may have cirrhosis
(Daniel, 2022).
The amount of bilirubin in your blood is determined via a bilirubin test. The result
shows elevated direct and indirect bilirubin (Lee at al., 2021). Direct bilirubin (DB) levels
rise in liver cirrhosis because of portal flow distortion, intrahepatic cholestasis, and
impaired hepatic bilirubin clearance (Lee at al., 2021). Meanwhile, hemolysis is triggered
36
by portosystemic shunting and splenomegaly, which raises the level of indirect bilirubin
(Lee at al., 201).
CHEST X-RAY (APRIL 08, 2023)
Clinical Information: None provided.

Comparison: None
Reference study: Whole abdomen ultrasound 03/03/2023
Procedure: Chest AP
Findings:
Hazy densities ae seen in the right lung base.

Heart is not enlarged.
Aorta is calcified.
Diaphragm and both costophrenic sulci are intact.
Osteophytes are seen along the margins of thoracic vertebra.
IMPRESSION:
Hazy densities, right lower lung – consider consolidation vs. atelectasis.

Atherosclerotic aorta
Thoracic spondylosis
Implications:
The patient’s right lower lung has hazy densities, might consider consolidation vs.
atelectasis.
37
VI. PATHOPHYSIOLOGY
38
39
NARRATIVE
Choledocholithiasis is caused by stones either first forming in the common bile
duct (CBD) or passing through the cystic duct into the CBD from the gallbladder.
Symptoms and complications result when the CBD is blocked by gallstones.
Degenerative liver disease known as liver cirrhosis is characterized by the replacement
of normal liver tissue with diffuse fibrosis that affects the liver's structure and function.
Cholesterol stones are commonly found in corpulent patients with low actual work or
patients that have as of late deliberately shed pounds. Hepatocyte lipid accumulation is
the hallmark of fatty liver. Simple fatty infiltration, a benign condition known as fatty liver,
is one form of nonalcoholic fatty liver disease (NAFLD). However, the metabolic
syndrome, which includes obesity, dyslipidemia, hypertension, and glucose intolerance,
increases the likelihood that a patient will have NASH rather than simple steatosis.
Although the process of pathogenesis is poorly understood, it appears to be connected
to insulin resistance (such as in metabolic syndrome or obesity). Biliary obstruction in the
liver and common bile duct (gallbladder stones) is a chronic impairment of bile excretion.
An imbalance in the chemical composition of bile within the gallbladder is thought to cause
gallstones. The majority of the time, the cholesterol in the bile reaches an excessive level,
resulting in stones. If the gallstones become lodged in the bile ducts that run between the
liver and the small intestine, a serious problem can arise. This can prevent bile from
flowing from the gallbladder and liver, which can result in pain, jaundice, and fever.
Grouping of hepatic cholesterol increments, bile acids, atoms combined from cholesterol
in the liver are impacted or supersaturation of biles.
A wide range of abnormalities caused by cirrhosis affect immune system cellular
and soluble components at the liver and throughout the body. At the point when liver cells
are harmed, AST spills out into the circulatory system and the degree of AST in the blood
becomes raised. A lack of conversion of enteric ammonia into urea, its entry into systemic
circulation via portasystemic shunting, or both have been linked to elevated plasma
ammonia levels in hepatic cirrhosis. Glucuronyl conjugation of bilirubin and biliary
excretion of conjugated bilirubin are markedly impaired in advanced cirrhosis, resulting in
jaundice. When blood pressure in the portal vein—the blood vessel that carries blood
from the digestive organs to the liver—is too high, cirrhotic ascites occur. As the tension
ascents, kidney capability declines, and liquid develops in the midsection and legs (fringe
edema). Expansion in intrahepatic vascular obstruction because of enormous underlying
changes related with fibrosis and expanded vascular tone in the hepatic microcirculation.
Non-selective beta-blockers are important in the management of cirrhosis because they

lower portal pressure; however, in patients with refractory ascites, they should be used
with caution. Patients are given lactulose to reduce the amount of toxins in their blood,
like ammonia. Toxins can accumulate in the blood of people with liver disease. The use
of diuretics allows sodium to be lost in the urine. Inhibiting chloride and sodium
reabsorption in the thick ascending limb of the loop of Henle is done with furosemide, a
loop diuretic. Spironolactone is an aldosterone antagonist that increases natriuresis and
preserves potassium by primarily acting on the distal tubules. In the initial treatment of
cirrhosis-related ascites, spironolactone is the drug of choice.
40
VII. MEDICAL AND SURGICAL MANAGEMENT
IDEAL PROCEDURES
Therapeutic paracentesis
The medical management of ascites includes dietary sodium restriction and taking
medication known as water tablets or diuretics (Wong, 2011). The patient must be
monitored regularly for any electrolyte imbalances, renal failure, and over-diuresis (Wong,
2011). Adequate treatment of ascites has improved medical management and focuses
on prevention of complications remains essential (Kuper, 2007). The ideal treatment for
advanced cirrhosis and ascites is liver transplantation which corrects impaired liver
function and portal hypertension (Wong, 2011).
Peritoneal Dialysis
Peritoneal Dialysis Insertion is an effective and safe treatment for patients with
ascites and kidney failure that uses the lining of the abdomen to filter the blood (Hingwala
et al., 2017). Peritoneal dialysis catheters have different shapes; they may be pigtail-
curled, swan-neck, or straight), lengths, and numbers of the Dacron cuffs and is
composed of flexible silicone tube that has several side holes to provide drainage and
absorption of dialysate. (Ellsworth, 2021). The procedure begins with a preoperative
assessment to determine the patient’s most appropriate type of catheter, insertion site,
and exit site (Crabtree, 2017).
Bariatric and metabolic surgery

The bariatric and metabolic surgery has reportedly made development and has
benefits regarding weight loss and improvement of some metabolic diseases, it leads to
significantly better long-term compared to patients that were conservatively treated
(Pouwels et al., 2022). Bariatric surgery has been considered the most effective treatment
for patients with morbid obesity and metabolic comorbidities. It also has effects on weight
loss and also in metabolic alterations (Olivos et al., 2016)
Liver transplant
If cirrhosis progresses and your liver is severely damaged, a liver transplant may
be the only treatment option. This is a major operation that involves removing your
41
diseased liver and replacing it with a healthy liver from a donor. You will probably have to
wait a long time for a suitable donor liver to become available.
ACTUAL PROCEDURES
Peritoneal Dialysis Insertion
Peritoneal dialysis insertion is a procedure that removes waste products and other
excess fluid in the blood. Peritoneal dialysis can be performed laparoscopically,
percutaneously, or through open surgery in which the patient is being sedated and
requires local or general anesthesia (Ellsworth, 2021). The catheter is usually inserted
near the belly button and carries the dialysate in and out of the abdomen. Due to decrease
kidney function, it is medically necessary since the kidney does not function correctly in
cleaning the waste and started to build up toxins in the blood. The patient is still for
scheduling of peritoneal dialysis catheter insertion, but still has not been inserted up until
the last day of assessment.
DRUG STUDY
1. Generic Name
➢ Propranolol
2. Brand Name
➢ Oranol
3. Dosage
➢ 10mg
4. Timing
➢ BID (8am & 6pm)
5. Route
➢ Oral
6. Mechanism of Action
➢ Propranolol is a nonselective β-adrenergic receptor antagonist.2 Blocking
of these receptors leads to vasoconstriction, inhibition of angiogenic factors
like vascular endothelial growth factor (VEGF) and basic growth factor of
fibroblasts (bFGF), induction of apoptosis of endothelial cells, as well as
down regulation of the renin-angiotensin-aldosterone system
7. Indications
➢ Propranolol is indicated to treat hypertension.10,9 Propranolol is also
indicated to treat angina pectoris due to coronary atherosclerosis, atrial
42
fibrillation, myocardial infarction, migraine, essential tremor, hypertrophic
subaortic stenosis, pheochromocytoma, and proliferating infantile
hemangioma.
8. Contraindications
➢ Asthma, COPD, Severe sinus bradycardia or 2°/3° heart block (except in
patients with functioning artificial pacemaker), Cardiogenic shock,
Uncompensated congestive heart failure, Hypersensitivity, Overt heart
failure, Sick sinus syndrome without a permanent pacemaker.
9. Adverse Effects
➢ CNS: fatigue, weakness, anxiety, dizziness, drowsiness, insomnia, memory
loss, mental depression, mental status changes, nervousness, nightmares.
➢ EENT: blurred vision, dry eyes, nasal stuffiness.
➢ Resp: bronchospasm, wheezing.
➢ CV: ARRHYTHMIAS, BRADYCARDIA, CHF, PULMONARY EDEMA,
orthostatic hypotension, peripheral vasoconstriction.
➢ GI: constipation, diarrhea, nausea.
➢ GU: erectile dysfunction, decreased libido.
➢ Derm: itching, rashes.
➢ Endo: hyperglycemia, hypoglycemia (increased in children).
➢ MS: arthralgia, back pain, muscle cramps.
➢ Neuro: paresthesia.
➢ Misc: drug-induced lupus syndrome.
10. Nursing Responsibilities
➢ Assessment: Assess heart rate, ECG, and heart sounds, especially during
exercise (See Appendices G, H). Report immediately an unusually slow
heart rate (bradycardia) or signs of other arrhythmias, including palpitations,
chest discomfort, shortness of breath, fainting, and fatigue/weakness.
Assess blood pressure (BP) periodically and compare it to normal values to
help document antihypertensive effects. Assess BP when the patient
assumes a more upright position (lying to standing, sitting to standing, lying
to sitting). Document orthostatic hypotension and contact the physician
when systolic BP falls >20 mm Hg or diastolic BP falls >10 mm Hg.
➢ Interventions: Assess pulse for quality, regularity, and bradycardia. Monitor
EKG for cardiac arrhythmias. Assess fingers for color, and numbness
(Raynaud’s). Assess for evidence of HF (dyspnea [particularly on exertion
or lying down], night cough, peripheral edema, distended neck veins).
Monitor I&O (increased weight and decreased urinary output may indicate
HF). Assess for rash, fatigue, and behavioral changes. Therapeutic
43
response time ranges from a few days to several wks. Measure B/P near
the dosing interval (determines if B/P is controlled throughout the day).
➢ Health Teaching: Do not abruptly discontinue the medication. Compliance
with the therapy regimen is essential to control hypertension, arrhythmia,
and anginal pain. To avoid the hypotensive effect, slowly go from lying to
standing. Avoid tasks that require alertness, and motor skills until a
response to the drug is established. Report excessively slow pulse rate
(less than 50 beats/min), peripheral numbness, and dizziness. Do not use
nasal decongestants, or OTC cold preparations (stimulants) without
physician approval. Restrict salt and alcohol intake.
44
1. Generic Name
➢ Lactulose
2. Brand Name
➢ Duphalac
3. Dosage
➢ 30cc
4. Timing
➢ OD (8pm)
5. Route
➢ Oral
➢ Constipation: Hyperosmotic agent increases stool water contents, softens
stool, promotes peristalsis, and reduces blood ammonia concentration.
➢ Portal systemic encephalopathy: Breakdown of lactulose to organic acids
by colonic bacteria acidifies colonic contents, thereby subsequently
inhibiting diffusion of ammonia back to blood; agent also enhances diffusion
of NH3 from the blood into the gut, where it is converted to NH4+
7. Indications
➢ Prevention, and treatment of portal-systemic encephalopathy (including
hepatic pre-coma, and coma); treatment of constipation.
➢ Galactosemia (patients require a low-galactose diet)
9. Adverse Effects
➢ Confusion, decreased urine, dizziness, dry mouth, fainting, fast or irregular
heartbeat, increased thirst, irritability, lightheadedness, loss of appetite,
mood changes, muscle pain, cramps, or twitching, nausea or vomiting,
numbness or tingling in the hands, feet, or lips, restlessness, seizures,
severe diarrhea, swelling of the feet or lower legs, trouble breathing,
unusual tiredness or weakness
➢ Assessment
➢ Interventions: Encourage adequate fluid intake. Assess bowel sounds for
peristalsis. Monitor daily pattern of bowel activity and stool consistency;
record time of evacuation. Assess for abdominal disturbances. Monitor
serum electrolytes in pts with prolonged, frequent, and excessive use of
medication.
45
➢ Health Teaching: Evacuation occurs within 24–48 hrs of the initial dose.
Institute measures to promote defecation: increase fluid intake, exercise,
and high-fiber diet.
46
1. Generic Name
➢ Spironolactone
2. Brand Name
➢ Aldactone
3. Dosage
➢ 100mg
4. Timing
➢ BID (8am & 6pm)
5. Route
➢ Oral
➢ Aldosterone antagonist with diuretic and antihypertensive effects;
competitive binding of receptors at aldosterone-dependent Na-K exchange
site in distal tubules results in increased excretion of Na+, Cl-, and water
and retention of K+ and H+
➢ Increases testosterone clearance and estradiol production; blocks
conversion of potent androgens to weaker ones in peripheral tissues
7. Indications
➢ Management of edema associated with excessive aldosterone excretion or
with HF; hypertension; cirrhosis of the liver with edema or ascites,
hypokalemia, nephrotic syndrome, severe HF; primary hyperaldosteronism.
OFF-LABEL: Treatment of edema, hypertension in children, female acne,
and female hirsutism.
➢ Hypersensitivity, Addison disease or other conditions associated with
hyperkalemia, Coadministration with eplerenone.
9. Adverse Effects
These common side effects of spironolactone happen in more than 1 in 100 people. There
are things you can do to help cope with them:
➢ Feeling dizzy
➢ Feeling or being sick
➢ Muscle or leg cramps
➢ Feeling tired or low in energy
➢ Breast pain and breast enlargement, including in men
Serious side effects
➢ Some people have serious side effects after taking spironolactone. Tell your
doctor or contact 111 straight away if:
47
• the whites of your eyes turn yellow, or your skin turns yellow,
although this may be less obvious on brown or black skin – these
can be signs of liver problems
• you get a slow or irregular heartbeat, tingling feeling, muscle
weakness or shortness of breath – these can be signs of potassium
levels being too high
• you're peeing less that usual or have dark, strong smelling pee, feel
thirsty or feel dizzy or light-headed – these can be signs of
dehydration
• you have diarrhoea, are peeing less than usual, are feeling or being
sick, and feel drowsy or confused – these can be signs of loss of
kidney function.

➢ Assessment: Weigh pt; initiate strict I&O. Evaluate hydration status by
assessing mucous membranes, and skin turgor. Obtain baseline serum
electrolytes, renal/hepatic function, and urinalysis. Assess for edema; note
location, and extent. Check baseline vital signs, note pulse rate/regularity
➢ Interventions: Monitor serum electrolyte values, esp. for increased
potassium, BUN, and creatinine. Monitor B/P. Monitor for hyponatremia:
mental confusion, thirst, cold/clammy skin, drowsiness, dry mouth. Monitor
for hyperkalemia: colic, diarrhea, muscle twitching followed by
weakness/paralysis, arrhythmias. Obtain daily weight. Note changes in
edema and skin turgor.
➢ Health Teaching: Expect an increase in the volume, and frequency of
urination. The therapeutic effect takes several days to begin and can last
for several days when the drug is discontinued. This may not apply if pt is
on a potassium-losing drug concomitantly (diet and use of supplements
should be established by the physician). Report irregular or slow pulse and
symptoms of electrolyte imbalance. Avoid foods high in potassium, such as
whole grains (cereals), legumes, meat, bananas, apricots, orange juice,
potatoes (white, sweet), and raisins. Avoid alcohol. Avoid tasks that require
alertness, and motor skills until a response to the drug is established (may
cause drowsiness).
48
1. Generic Name
➢ Tramadol
2. Brand Name
➢ Agoram
3. Dosage
➢ 50mg
4. Timing
➢ PRN (as needed)
5. Route
➢ Oral
➢ Non-opioid-derived synthetic opioid; centrally acting analgesic, but may act
at least partially by binding to opioid mu receptors, causing inhibition of
ascending pain pathways.
7. Indications
➢ Management of moderate to moderately severe pain. Extended-Release:
Around-the-clock management of moderate to moderately severe pain for
an extended period.
➢ Hypersensitivity to tramadol or opioids. Known or suspected gastrointestinal
obstruction, including paralytic ileus. Concurrent use of monoamine oxidase
inhibitors (MAOIs) or use within the last 14 days. Children <12 years.
Postoperative management in children <18 years following tonsillectomy
and/or adenoidectomy. Severe/acute bronchial asthma in an unmonitored
setting or in absence of resuscitative equipment. Significant respiratory
depression.
9. Adverse Effects
➢ Headaches, Feeling sleepy, tired, dizzy or "spaced out", Feeling or being
sick (nausea or vomiting), Constipation, Dry mouth, Sweating, Low energy.
➢ Assessment: Assess onset, type, location, and duration of pain. Assess
drug history, esp. carbamazepine, analgesics, CNS depressants, MAOIs.
Review past medical history, esp. epilepsy, and seizures. Assess renal
function, LFT.
➢ Interventions: Monitor pulse, B/P, and renal/hepatic function. Assist with
ambulation if dizziness or vertigo occurs. Dry crackers and cola may relieve
nausea. Palpate bladder for urinary retention. Monitor daily pattern of bowel
49
activity, and stool consistency. Sips of water may relieve dry mouth. Assess
for clinical improvement and record the onset of relief of pain.
➢ Health Teaching: May cause dependence. Avoid alcohol, and OTC
medications (analgesics, sedatives). May cause drowsiness, dizziness, and
blurred vision. Avoid tasks requiring alertness, and motor skills until a
response to the drug is established. Report severe constipation, difficulty
breathing, excessive sedation, seizures, muscle weakness, tremors, chest
pain, and palpitations.
50
1. Generic Name
➢ Furosemide
2. Brand Name
➢ Fusidix
3. Dosage
➢ 40mg
4. Timing
➢ BID (8am & 6pm)
5. Route
➢ Oral
➢ Loop diuretic; inhibits reabsorption of sodium and chloride ions at proximal
and distal renal tubules and loop of Henle; by interfering with the chloride-
binding cotransport system, causes increases in water, calcium,
magnesium, sodium, and chloride.
7. Indications
➢ Treatment of edema associated with HF and renal/hepatic disease; acute
pulmonary edema. Treatment of hypertension, either alone or in
combination with other antihypertensives.
➢ PO/IV/IM
• Documented hypersensitivity to furosemide or sulfonamides
• Anuria
➢ SC on-body infusor
• Documented hypersensitivity to furosemide or sulfonamides
• Anuria
• Hepatic cirrhosis or ascites
9. Adverse Effects
➢ Peeing more than normal, Feeling thirsty, Dry mouth, Headaches, Feeling
confused or dizzy, Feeling or being sick (nausea or vomiting).
➢ Assessment: Check vital signs, esp. B/P, pulse, for hypotension before
administration. Assess baseline serum electrolytes, esp. for hypokalemia.
Assess skin turgor, and mucous membranes for hydration status; observe
for edema. Assess muscle strength and mental status. Note skin
temperature and moisture. Obtain baseline weight. Initiate I&O monitoring.
➢ Interventions: Monitor B/P, vital signs, serum electrolytes, I&O, and weight.
Note the extent of diuresis. Watch for symptoms of electrolyte imbalance:
51
Hypokalemia may result in changes in muscle strength, tremors, muscle
cramps, altered mental status, and cardiac arrhythmias; hyponatremia may
result in confusion, thirst, and cold/clammy skin.
➢ Health Teaching: Expect increased frequency, and volume of urination.
Report palpitations, signs of electrolyte imbalances (noted previously), and
hearing abnormalities (sense of fullness in ears, tinnitus). Eat foods high in
potassium such as whole grains (cereals), legumes, meat, bananas,
apricots, orange juice, potatoes (white, sweet), and raisins. Avoid sunlight
and sunlamps.
52
1. Generic Name
➢ Zinc Sulfate Syrup
2. Brand Name
➢ Orazinc
3. Dosage
➢ 10ml
4. Timing
➢ OD
5. Route
➢ Oral
➢ Zinc inhibits cAMP-induced, chloride-dependent fluid secretion by inhibiting
basolateral potassium (K) channels, in in-vitro studies with rat ileum.
7. Indications
➢ To treat or prevent low levels of zinc alone and together with oral
rehydration therapy (ORT).
➢ glucose-6-phosphate dehydrogenase (G6PD) deficiency.
➢ a high amount of oxalic acid in urine.
➢ iron metabolism disorder causing increased iron storage.
➢ sickle cell anemia.
➢ calcium oxalate kidney stones.
➢ decreased kidney function.
➢ anemia from pyruvate kinase and G6PD deficiencies.
9. Adverse Effects
➢ Breathing in zinc sulfate can irritate the respiratory tract, and cause nausea,
vomiting, stomach ache, dizziness, depression, metallic taste in the mouth,
and death.
➢ Monitor Zinc deficiency
• Delayed healing
• Decreased sense of taste
• Decreased sense of smell
➢ Monitor HDL
➢ No caffeine, dairy products
53
VIII. NURSING MANAGEMENT
PRIORITY PROBLEM #1: Excess Fluid Volume related to compromised regulatory

mechanism secondary to cirrhosis of the liver as manifested by abdominal
distention
Subjective Cues:
> “nabantayan gyud nako nga ga dako gyd akong tiyan” as verbalized
Objective Cues:
> Abdominal distention noted

> Decreased urine output @ 200-240 cc/day
> Abdominal girth of 104.5 cm
> Elevated BUN
GOALS AND OBJECTIVES
Short Term Goals:
After 6 hours of nursing intervention, patient will demonstrate behaviors to monitor fluid
status and reduce recurrence of fluid excess.
Long Term Goals:
After 2 days of nursing intervention, patient will be able to maintain a balance in fluid
volume with fluid and sodium restriction and maintain an acceptable body weight.
NURSING INTERVENTIONS AND RATIONALE
INDEPENDENT:
1. Monitor vital signs

r: to established baseline data.
2. Evaluate total daily intake. Maintain daily of input and output.
r: to reveal changes that should be made in client’s dietary intake.
3. Monitor abdominal girth
r: reflects accumulation of fluid.
4. Monitor BP.
r: BP elevations are usually associated with fluid volume excess.
5. Weigh the patient daily at the same each day.
r: daily body weight is best monitor of fluid status.
54
DEPENDENT:
1. Restrict sodium and fluids as ordered.
r: sodium may be restricted to minimize fluid retention in extravascular

spaces.
2. Administer medications as indicated: Spironolactone, Furosemide
r: used with caution to control edema and ascites, block the effect of
aldosterone, and increase water excretion while sparring potassium.
COLLABORATIVE:
1. Review medical regimen with family members.
r: to provide information/assistance as necessary
EVALUATION
GOALS ARE PARTIALLY MET
After 2 days of nursing intervention, the patient was able to demonstrate

behaviors to monitor fluid status and reduce recurrence of fluid excess.
55
PRIORITY PROBLEM #2: Imbalance nutrition: less than body requirements related
to loss of appetite secondary to ascites as evidenced by refusal to eat
ASSESSMENT
Subjective Cues:
> “makakaon rakog 3-4 ka kutsara nga lugaw sir.” as verbalized
Objective Cues:
> Weight loss
> Lack of appetite
> Abdominal distention noted
Short Term Goals:
· After 5 hours of nursing intervention, patient’s appetite will improve from 3 tbsp to at least
5 tbsp per meal.
Long Term Goals:
· After 2 days of nursing intervention, patient will demonstrate healthy eating pattern.
NURSING INTERVENTION AND RATIONALE
INDEPENDENT:
1. Monitor vital signs
r: for baseline data
2. Discuss eating habits including food preferences.
r: to stimulate appetite
3. Recommend small, frequent meals
r: poor tolerance to larger meals may be due to increased intra-

abdominal pressure/ ascites.
4. Restrict intake of caffeine, gas-producing or spicy and excessively hot or cold

foods.
56
r: aids in reducing gastric irritation and abdominal discomfort that may
impair oral intake/digestion.
5. Provide assistance with activities as needed. Promote undisturbed rest

periods, especially before meals.
r: conserving energy reduces metabolic demands on the liver and

promotes cellular regeneration.
5. Limit foods that induce nausea or vomiting
r: these measures may be helpful in increasing food intake.
DEPENDENT:
1. Provide nutriotional supplements as appropriate or ordered.
r: to further strengthen the body.
COLLABORATIVE:
1. Discuss with MD the potential need for referral to a dietitian.
r: to individualize the patient’s plan of care regarding nutrition.
EVALUATION
GOALS NOT MET. After 8 days of nursing intervention, the patient was not able to
improve her appetite and was not able to demonstrate healthy eating pattern.
57
PRIORITY PROBLEM #3: Activity Intolerance related to generalized body
weakness secondary to progressive disease state as manifested by inability to
perform usual ADLs and weak in appearance.
ASSESSMENT
Subjective Cues:
> “wala kaayo koy gana e lihok2 akong lawas sir” as verbalized
Objective Cues:
> Difficulty initiating movements

> ADLs status @ 2 (assist with person)
> Decreased ROM
Short Term Goals:
· After 8 hours of nursing intervention, the patient will participate willingly in necessary
activity.
Long Term Goals:
· After 2 days of nursing intervention, patient will be able to conserve energy and verbalize
relief from fatigue.
NURSING INTERVENTION AND RATIONALE
INDEPENDENT:
1. Evaluate patient’s current activity tolerance.
r: provide cooperative baseline.
2. Adjust activity and reduce intensity of task that may cause undesired physiological
changes.
r: to prevent over exertion.
3. Increase exercise and activity levels gradually.
58
r: enhances activity tolerance
4. Demonstrate/ Assist the patient while doing ADL
r: to protect patient from injury.
6. Teach methods to conserve energy such as sitting than standing while dressing.
r: helps minimize waste of energy
6. Encourage client to do whatever possible e.g self-care
r: provides for sense of control and feeling of accomplishment
DEPENDENT:
1. Assess the need for ambulation aids (e.g cane, walker)
r: assistive devices enhance the mobility of the patient by helping her

overcome limitations.
COLLABORATIVE:
1. Provide referral to other disciplines as indicates (e.g physical therapies and occupational
therapies).
r: to develop individually appropriate therapeutic regimens.
EVALUATION
GOALS ARE PARTIALLY MET. After 8 hours of nursing intervention, the patient
was able to participate in treatment regimen/activities.
59
IX. DISCHARGE PLAN
Goals:
Upon discharge the patient will be able to:
* Fully comprehend on the prognosis of related condition
* To understand further home management and therapies to provide appropriate care as
needed
* To help the patient and significant others in preventing occurrence of complications and
support the restorative process of the patient’s condition.
* Fort the patient’s family to provide emotional and psychological support to the patient
during the post-hospitalization phase.
Medication:
• Take your medicines exactly as directed.
• Talk with your provider before taking vitamins, over-the-counter medicines, or
herbal supplements. Some herbal supplements may be toxic to the liver.
Painkillers called NSAIDs (nonsteroidal anti-inflammatory drugs), such as
ibuprofen, can harm the liver if you have cirrhosis.
• Don't take aspirin or other blood-thinning medicines unless directed by your
provider.
• Discuss vitamin supplements and deficiencies with your provider.
• Ask your provider about getting vaccines for viruses that can cause liver diseases.
Activity:
Unless you are told otherwise
● Avoid lifting, pulling or pushing any heavy objects (more than 10 pounds). For the
first 3 days after discharge.
● Avoid straining or any activity in which you hold your breath and exert yourself or
“bear down,” such as when having a bowel movement or lifting yourself up, ask
your physician about a laxative or stool softener if you become constipated.
● Do not drive for the first 3 days after discharge
Diet
● Reduce sodium intake: Patients with liver cirrhosis often have fluid retention and
swelling, so it's important to limit their sodium intake to less than 2,000 milligrams
per day.
● Increase protein intake: The liver plays a key role in protein metabolism, and
patients with cirrhosis may have trouble processing protein. However, they still
need to consume enough protein to maintain muscle mass and prevent
malnutrition. The recommended daily protein intake is about 1.2 to 1.5 grams per
kilogram of body weight.
● Avoid alcohol: Alcohol can further damage the liver and worsen cirrhosis. Patients
with liver cirrhosis should avoid all alcoholic beverages.
● Eat small, frequent meals: Patients with liver cirrhosis may experience a decreased
appetite or feel full quickly. Eating small, frequent meals can help them get the
nutrients they need without feeling overwhelmed.
● Avoid raw or undercooked meat and seafood: These foods may contain harmful
bacteria that can cause infections, which are particularly dangerous for patients
with liver cirrhosis.
60
● Avoid high-fat foods: Patients with liver cirrhosis may have trouble digesting fats,
so it's best to avoid foods that are high in saturated and trans fats.
● Consult with a registered dietitian: A registered dietitian can help develop a
personalized diet plan that meets the patient's specific needs and preferences
while managing liver cirrhosis.
A healthy lifestyle:
● Stop drinking alcohol: Alcohol is one of the leading causes of cirrhosis, so it's
important to avoid it completely.
● Follow a healthy diet: Patients with cirrhosis should follow a healthy diet that is low
in salt and saturated fat, and high in protein, fiber, and nutrients.
● Exercise regularly: Regular exercise can help improve muscle strength, reduce the
risk of complications, and improve overall health. Patients should aim for at least
30 minutes of moderate exercise, such as walking or cycling, on most days of the
week.
● Manage stress: Stress can worsen cirrhosis symptoms and increase the risk of
complications. Patients should try to manage stress through techniques such as
relaxation exercises, meditation, or counseling.
Hygiene:
● Wash hands frequently: Encourage the patient to wash their hands frequently,
especially before eating or touching their face, and after using the bathroom or
being in contact with someone who is sick.
● Keep the home clean: Make sure the patient's home is clean and free of dust,
mold, and other allergens that can worsen their symptoms and increase the risk of
infections.
● Practice good oral hygiene: Patients with cirrhosis may have an increased risk of
gum disease, so it's important to encourage them to brush their teeth twice a day,
floss regularly, and visit the dentist for regular check-ups.
● Avoid sharing personal items: Encourage the patient to avoid sharing personal
items such as razors, toothbrushes, or towels with others to reduce the risk of
infections.
Spiritual teachings
● Provide care by simply asking patient how you can support them based on their
religion and beliefs
● Encourage the patient to continuously do religious practices like praying that will
help them feel better.
● Advice the client’s family to use their gifts of presence and touch as it boosts their
sense of belongingness
61
X. RESULTS AND DISCUSSION`
The researchers were able to compare the actual and ideal nursing and medical
intervention to the patient’s condition. Not only did we assess the patient’s condition
during the days of the assessment process, but we also included the patient’s immediate
family members, specifically his mother who was there the entire time. Emotional aspects
in their well-being were assessed as well since it is stated that nursing care is not limited
to the care of the patient but also includes the care of the significant others. For such
patients and family is a single unit of care.
Based on the study, there are various medical interventions that can be done to
facilitate complete recovery of the patient’s condition. There are also things that will help
and allow the patient to recover without having complications. Thus, there are gaps
between ideal and actual medical-surgical interventions. This is the reason why nursing
care should be focused before and during the hospital stay of the patient.
62
XI. CONCLUSION
In conclusion, this case study explored the disease process, and the medical-
surgical and nursing management of liver cirrhosis secondary to non-alcoholic fatty liver
disease, choledocholithiasis. The researchers were able to trace the pathophysiologic
process of liver cirrhosis secondary to non-alcoholic fatty liver disease,
choledocholithiasis, integrate its medical-surgical management into the nursing process,
and systematically identify the priority nursing problems to come up with comprehensively
developed care plans and discharge instructions.
63
XII. REFERENCES
BMC Endocrine Disorders volume 22, Article number: 63 (2022) (Pouwels, S., Sakran,
N., Graham, Y., Leal, A., Pintar, T., Yang, W., Kassir, R., Singhal, R., Mahawar,
K., & Ramnarain, D.)
Burke, & Rossiaky. (2021, December 14). Aspartate Aminotransferase (AST) Test.
Healthline. Retrieved April 19, 2023, from https://www.healthline.com/health/ast.
Daniel. (2022, July 14). Overview of ALT and AST Liver Enzymes. Verywell Health.
Retrieved April 19, 2023, from https://www.verywellhealth.com/liver-enzymes-
1759916
Lee, H. A., Jung, J. Y., Lee, Y. S., Jung, Y. K., Kim, J. H., An, H., Yim, H. J., Jeen, Y. T.,
Yeon, J. E., Byun, K. S., Um, S. H., & Seo, Y. S. (2021). Direct Bilirubin Is More
Valuable than Total Bilirubin for Predicting Prognosis in Patients with Liver
Cirrhosis. Gut and liver, 15(4), 599–605. https://doi.org/10.5009/gnl20171
Management of ascites in cirrhosis. Journal of Gastroenterology and Hepatology.

(Wong, F. 2011)
MedlinePlus. (2022, April 5). BUN (Blood Urea Nitrogen): MedlinePlus Medical Test.
Retrieved April 19, 2023, from https://medlineplus.gov/lab-tests/bun-blood-urea-
nitrogen/
MedlinePlus. (2022, June 7). Albumin Blood Test: MedlinePlus Medical Test. Albumin
Blood Test: MedlinePlus Medical Test. Retrieved April 19, 2023, from
https://medlineplus.gov/lab-tests/albumin-blood-test/
National Kidney Foundation. (2016, January 7). Tests to Measure Kidney Function,
Damage and Detect Abnormalities. Retrieved April 19, 2023, from
https://www.kidney.org/atoz/content/kidneytests
Peritoneal Dialysis Catheters to Treat Refractory Non-Malignant Ascites. Sage Journals

Volume 37, Issue 4 (Hingwala, J., Whitlock, R., and Komenda, P. 2017)
Peritoneal Dialysis Catheter Insertion. ScienceDirect. (Crabtree, J., & Chow, K. 2017)
Peritoneal dialysis. National Library of Medicine (Sachdeva, B., Zulfiqar, H., and
Aeddula, N. 2022)
Percutaneous Peritoneal Dialysis Catheter Insertion by a Nephrologist: A New, Simple,

and Safe Technique. National Library of Medicine (Al-Hwiesh, A..K., 2014)
Peritoneal Dialysis Catheter Insertion. Medscape. (Ellsworth, P. 2021)
The role of bariatric surgery in the management of nonalcoholic fatty liver disease and
metabolic syndrome. Science Direct. (Olivos, N., Valdes, P., Salinas, C., Uribe,
M. & Sanchez, N., 2016)
64

Case Study Liver Cirrhosis

Uploaded by

Copyright:

Available Formats

Case Study Liver Cirrhosis

Uploaded by

Document Information

Original Description:

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Case Study Liver Cirrhosis

Uploaded by

Copyright:

Available Formats

Capitol University

A CASE STUDY ON LIVER CIRRHOSIS SECONDARY TO NON-ALCOHOLIC FATTY

Mr. Josileo G. Bonzo, RN

Background of the study

Objective of the Study

The significance of the case study in relation to the theme

Scope and limitations of the study

II. PATIENT'S PROFILE ............................................................................................... 10

Nursing Health History

Patient's Developmental Stage

III. THEORETICAL AND CONCEPTUAL FRAMEWORK ............................................ 25

IV. ANATOMY AND PHYSIOLOGY ............................................................................. 26

V. DIAGNOSTIC AND LABORATORY TESTS ............................................................ 28

VII. MEDICAL AND SURGICAL MANAGEMENT ........................................................ 41

VIII. NURSING MANAGEMENT……………………………….…………………………….54

IX. DISCHARGE PLAN……………………………………………………………………….60

X. RESULTS AND DISCUSSION…………………………………………………………...62

Background of the Study

Patient X is a 69-year-old female, who was admitted at Northern Mindanao Medical

Non-alcoholic fatty liver disease (NAFLD) is becoming a leading cause of liver

Objective of the Study

Significance of the Study

Scope and Delimitation

1. Cirrhosis - a condition in which your liver is scarred and permanently damaged.

Nursing Health History

Patient X is a sixty-nine-years-old who is female born on 26th of May, 1954.

History of Present Illness

Patient X is a known case of liver cirrhosis secondary to non-fatty liver disease

Past Health History

Health perception and health management pattern

Prior to Admission: Patient is positively waiting about the upcoming peritoneal

During Admission: Patient shows frustration (dissatisfaction arising from

Activity and exercise pattern

During Admission: Patient needs an assistance in terms of her hospitalization

ACTIVIES OF DAILY LIVING/ MOBILITY STATUS

Legend: 0 – Total Independence

1 – Assist with Device

3 – Assist with Device and Person

Sleep and rest pattern

During Admission: Patient X trouble sleeping during hospitalization because of

Cognitive and perceptual pattern

During Admission: Patient X is pausing when being questioned to think which

Self-perception and self-concept pattern

Prior to Admission: Patient experienced disturbed body image due to the

Roles and relationships pattern

During Admission: Patient X has been dependent on her daughter-in-law since

Sexuality and reproduction patterns

During Admission: Patient X shows no further reproductive problems. In

Coping and stress tolerance pattern

Value- belief pattern

Missing teeth and carries

Respiratory: (+) orthopnea

Stool: yellowish watery

Uncoordinated gait (with assist

Non-pitting bipedal edema

Day 2 of Assessment (April 4, 2023)

Missing teeth and carries

Respiratory: (+) orthopnea