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A CASE STUDY FOR TO CONSIDER HEPATIC ENCEPHALOPATHY SECONDARY TO LIVER CIRRHOSIS

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milagros waminal

on 16 February 2011

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Transcript of A CASE STUDY FOR TO CONSIDER HEPATIC ENCEPHALOPATHY SECONDARY TO LIVER CIRRHOSIS

A CASE STUDY FOR TO CONSIDER HEPATIC ENCEPHALOPATHY SECONDARY TO LIVER CIRRHOSIS INTRODUCTION The liver is an important organ that performs a number of useful functions for the body. The liver helps controlling the infections by removing harmful bacteria and toxins from the blood. Liver is the processing unit for nutrients, hormones and drugs in the body. It produces proteins that help in regulation of blood clotting. Bile is produced by the liver that helps in absorbing fats like cholesterol and other fat soluble vitamins. You can read more on liver function.”(Buzzle.com,2010). “Statistics from the Centers for Disease Control and Prevention (CDC) rank mortality related to chronic liver disease and cirrhosis as the 12th most common cause of death in adults in the U.S. Hepatic encephalopathy (HE) is a brain disorder caused by chronic liver failure, particularly in alcoholics with cirrhosis, which results in cognitive, psychiatric, and motor impairments In these patients, the number of functional liver cells is reduced, and some blood is diverted around the liver before toxins are removed. As a result, toxins such as ammonia and manganese can accumulate in the blood and enter the brain, where they can damage nerve cells and supporting cells called astrocytes.”(Butterworth.R., 2010) This case study aims to identify patient’s health needs and problems in order to identify goals to promote the general health needs and problems in order to identify goals to promote the general health of the patient by providing proper intervention through the application of nursing process. Submitted by:
RLE 9 Group 16 THFS
Medical Ward- NMMC Submitted to:
Rick Wilson Bunao, RN. MN.
Clinical Instructor

We choose this as our grand case study because we wanted to have a complex knowledge in caring for the client having liver cirrhosis despite of its many complications. And also as seniors we want to go deeper on our knowledge and skills and not merely the basic things we had learned about liver cirrhosis. In our case study, we chose Virginia Henderson’s theory as our based theory in rendering care to our patient. As we all know, Henderson’s theory the 14 basic needs of the patient with comprises of breathing, eating and
drinking adequately eliminating, moving and maintaining
desirable position resting and sleeping,
selecting suitable clothing keeping the body clean and well groom and protecting the integument, avoiding danger in the environment and injury, communicating with others in expressing feelings and worshipping according to ones faith. OBJECTIVES We will be able to enhance our knowledge in various concepts related to our patient’s condition, and skills in careful and thorough assessment, and rendering of nursing interventions involved in the management of our client’s case and also to develop positive attitudes by collaboration and sense of teamwork as we accomplish our case study using concepts that we have acquired from our Nursing Care Management subject Specific objectives 1. Identify and differentiate risk for Hepatic Encephalopathy and Liver Cirrhosis 2.Be aware in new ways and development in caring client having Hepatic Encephalopathy probably secondary to liver cirrhosis 3. Perform a careful and thorough assessment and gathering of data that are clinically significant and will be utilized as reliable cues for our care plans. 4. Further completion of data that will supplement our assessment, such as laboratory results and monitoring sheets. 5. Trace and familiarize the pathophysiology of our patient’s disease process.
6. Design individualized nursing care plans based on nursing diagnosis that are suitable to carry out.
CLIENT’S PROFILE Patient’s name : Mr. X
Address : Almasega, Anakan Gingoog City, Misamis Oriental
Birthday : November 8, 1953
Age : 57 years old
Sex : Male
Patient’s name : Mr. X
Address : Almasega, Anakan Gingoog
Birthday : November 8, 1953
Age : 57 years old
Sex : Male Educational background: High School Graduate
Nationality: Filipino
Religion: Roman Catholic
Marital status: Married by Law
Usual occupation: Spare Operator
Present occupation : Spare Operator
Information Given by : Wife
Reliability of historian : Good reliability
Chief Complaints : Admitted due to Fever, abdominal pain, shortness of breath Date Admitted : January 19, 2011, 8:30 PM
Diagnosis : To Consider Hepatic Encephalopathy Secondary to Liver Cirrhosis
Physician : Dr. Casiño
HISTORY OF PRESENT ILLNESS Two weeks prior to admission patient was noted to be jaundiced but just ignored it. Then four days prior to admission, while patient was working in his workplace, he suddenly experienced body weakness and the next day he has fever and did not go back to work from then on. He was given by his wife a medication (paracetamol) as an analgesic and for relieving fever until eight hours prior to admission patient defecated a black colored stool and experienced shortness of breath. He was then rushed to this hospital with abnormal vital signs: BP: 150/100 mmHg, RR: 28 cpm, HR:105 bpm, Temp:38.5 C HISTORY OF PAST ILLNESS Patient was diagnosed with Diabetes Mellitus, type 2 at the age of 26. He has maintenance medication of Metformin. He is also hypertensive. PERSONAL, ENVIRONMENT
& PSYCHOSOCAL HISTORY Patient X is married to a 57-year-old plain house wife for almost 27 years. They have five children; two girls and three boys, 26, 25, 24, 22, 21 respectively. During assessment, Patient X stated that he is working as a spare operator at a coco lumber in Gingoog City for more than 15 years. Patient also stated that he is a heavy alcoholic drinker and also a smoker. However, he managed to stop smoking but still he continued drinking alcoholic beverages even at the point he was diagnosed with DM. PHYSICAL
ASSESSMENT First day assessment
(Jan. 22, 2011)

• With Intravenous fluid of PNSS @ KVO Rate
• Actual food taken “Diet as Tolerated” without difficulty in swallowing.

• He eats three times a day consuming only half share of meal.

• About 350 mL of water being consumed each day without drinking coffee or soft drinks.

• Pallor and dry lips
• Pallor mucosa.
• Distinguish tastes
• With pallor gums and with missing teeth
• With dental caries



Second day assessment
(Jan. 26, 2011)

• With Intravenous fluid of PNSS @ KVO Rate
• DAT and takes only porridge in between meals and doesn’t take whole share of the served food.

• Consumes about 350 mL glasses of water everyday.

• Pallor and dry lips
• Pallor mucosa
• Distinguish tastes
• With pallor gums and with missing teeth
• With dental caries
NUTRITIONAL AND METABOLIC STATUS Final assessment
(February 2, 2011)

• With Intravenous fluid of PNSS @ KVO Rate
• DAT and takes only porridge in between meals and doesn’t take whole share of the served food

• Consumes about 350 mL glasses of water everyday.

• Pallor and dry lips
• Pallor mucosa
• Distinguish tastes
• With pallor gums and with missing teeth
• With dental caries
ELIMINATION PATTERN First day assessment
(Jan. 22, 2011)

•Has difficulty in defecating with rashes in the anus and defecates once a day with a dark red colored stool.

•Urinates with tea-colored urine with a total output of 350 cc in 8 hours

•Felt pain upon urinating and defecating.

•With normal daytime sweats

•With abdominal girth of 101 centimeters
Second day assessment
(Jan. 26, 2011)

• Defecate once a day with yellow-brown color stool, watery about 60cc.


• Total urine output in 8 hours: 350mL, Yellow-orange in color, three times per shift.

• With normal daytime sweats.

• With abdominal girth of 107.5 centimeters
Final assessment
(February 2, 2011)

• Defecate once a day with yellow-brown color stool, watery about 60cc.


• Total urine output in 8 hours: 350mL, Yellow-orange in color, three times per shift.

• With normal daytime sweats.

• With abdominal girth of 110 centimeters
ACTIVITY-EXERCISE PATTERN First day assessment
(Jan. 22, 2011)

 BP: 140/90 mmHg taken in the left arm; sidelying.
 HR: 105 bpm with irregular rhythm
 With capillary refill time of 4 sec
 On auscultation no heart murmurs heard.
 Skin cold to touch and glisten with non- pitting edema noted; with firm skin; T: 36.1
 With edematous leg with a circumference of 16inches
 With crackles heard upon auscultation at both lower lobe of the lungs.
 RR=32 cpm (tachypnic);
 Placed in side-lying position with 1 pillow at the back.
 Activities of daily living performance at level 4 code.
 Patient is weak at both lower extremities with muscle strength of 2/5 on both extremities and does not respond to any activity
Second day assessment
(Jan. 26, 2011)

BP: 130/90 mmHg taken in the left arm; sidelying.
HR: 89 bpm with irregular rhythm
With capillary refill time of 4 sec
On auscultation no heart murmurs heard.
Skin cold to touch and glisten with non- pitting edema noted; with firm skin ; T: 35.4 With edematous leg with a circumference of 14inches

With crackles heard upon auscultation at both lower lobe of the lungs.
RR=28 cpm (tachypnic);
Placed in side-lying position with 1 pillow at the back.
Activities of daily living performance at level 4 code.
Patient is weak at both lower extremities with muscle strength of 2/5 on both extremities and does not respond to any activity

Final assessment
(February 2, 2011)

 BP: 140/90 mmHg taken in the left arm; sidelying.
 HR: 90 bpm with irregular rhythm
 With capillary refill time of 4 sec
 On auscultation no heart murmurs heard.
 Skin cold to touch and glisten with non- pitting edema noted; with firm skin; T: 35
 With crackles heard upon auscultation at both lower lobe of the lungs. With edematous leg with a circumference of 11inches

 RR=28 cpm (tachypnic);
 Placed in side-lying position with 1 pillow at the back.

 Activities of daily living performance at level 4 code.
 Patient is weak at both lower extremities with muscle strength of 3/5 on both extremities and does not respond to any activity .
COGNITIVE-PERCEPTUAL PATTERN First day assessment
(Jan. 22, 2011)

• LOC conscious and coherent, oriented to time and place

• Pupil size of 2 mm at the right and 3mm in the left. Both are briskly reactive to light

• Has a facial symmetry

• Muscle strength in the lower and upper extremities:
> Right upper 5/5
> Left upper 5/5
> Right lower 2/5
> Left lower 2/5
Second day assessment
(Jan. 26, 2011)

• LOC: conscious and coherent, oriented to time and place

• Pupil size of 2 mm at the right and 3mm in the left. Both are briskly reactive to light

• Muscle strengths:
> Right & Left upper
extremities: 5/5
> Right & Left lower extremities: 2/5 Final assessment
(February 2, 2011)

• LOC: drowsy

• Patient is not able to respond directly upon asking.

• He is drowsy and always closes his eyes.

• Muscle strengths:
> Right & Left upper extremities: 5/5
> Right & Left lower extremities: 3/5

SLEEP-REST PATTERN First day assessment
(Jan. 22, 2011)

• Usually sleep between 8-9pm in the evening and usually wakes up at 6am in the morning with a nap in the afternoon

• Has no history of sleep disturbances
Second day assessment
(Jan. 26, 2011)

• Abnormal sleeping pattern. Sleeps for about 4-5 hours in a day.

• He is not able to do activities of daily living due to inadequate rest and sleep.

• He is always on a side lying position and is not able to ambulate anymore.










Final assessment
(February 2, 2011)

• Abnormal sleeping pattern.

• Sleeps for about 4-5 hours in a day.
• He is not able to do activities of daily living due to inadequate rest and sleep.
• He is always on a side lying position and is not able to ambulate anymore. SELF- PERCEPTION AND SELF-CONCEPT PATTERN First day assessment
(Jan. 22, 2011)

• “First time pagyud nako ni naadmit. Daan nako nga highblood ug diabetic.”
as verbalized by the patient

• “Luya man akong lawas, akong tiil gapanghupong, dato pani pagsulod nako sa emergency room.” as verbalized by the patient

Second day assessment
(Jan. 26, 2011)

• Patient is no longer able to respond when it comes to verbal communication.
Final assessment
(February 2, 2011)

• Patient is no longer able to respond when it comes to verbal communication.

. ROLE-RELATIONSHIP PATTERN First day assessment
(Jan. 22, 2011)

• Patient’s family and relatives are always there to support him all the time.

• His children are on his side giving support and care.


Second day assessment
(Jan. 26, 2011)

• Patient’s family and relatives are always there to support him all the time.

• His children are on his side giving support and care.

Final assessment
(February 2, 2011)

• Patient’s family especially his wife and his mother are very supportive to him. They never leave the patient alone. By then, it helps the patient to gain more strength.

• His family is almost with him all the time.

• His wife and his mother is encouraging him to fight and they are hoping that patient X will still recover.


COPING STRESS TOLERANCE PATTERN First day assessment
(Jan. 22, 2011)

• “Naguol kaayo mi sa nahitabo sa akong bana samot na nga galisod kaayo mi pagpangita ug kwarta” as stated by his wife

Second day assessment
(Jan. 26, 2011)

• “Dili na gyud namo makaya ang mga gasto diri sa hospital ug gakasamot mi ug kaguol ani” as stated by his wife. Final assessment
(February 2, 2011)

• Patient was advised by his physician to go home due to the poor prognosis of his disease condition. As a result, he has a low self esteem and feels down. He appears to be tired of his life and his suffering now due to his illness.

• The patient’s family also felt sad about what’s happening to their loved one but they can do nothing so they prefer to choose HAMA or home against medical advice because of financial problems.
VALUE –BELIEF PATTERN First day assessment
(Jan. 22, 2011)

• “Gaampo jud mi sa Ginoo nga unta maayuhan pa akong bana. Gasalig man gyapon mi sa Ginoo maski pa sa mga problema nga gaabot sa amoa karon” as stated by his wife
Second day assessment
(Jan. 26, 2011)

• “Gasamot na gyud ang sakit sa akong bana pero wala gyapon mi nawad-I ug paglaum ug pag-ampo sa Ginoo nga unta maayuhan pa siya” as stated by his wife.
Final assessment
(February 2, 2011)

• “Dili gyapon mi gakawad-an ug paglaum nga maayuhan akong bana ug naa pai milagro nga mahitabo sa iya” as stated by her wife. NURSING CARE PLAN Jan. 22, 2011 Acute pain related to compression of nerve due to intra-abdominal fluid accumulation as evidence by enlarged abdomen Objective data:
• Pain scale of 7/10
• restless
• muscle tension present
• irritable
• facial grimace
• guarding behavior
• abdominal girth 101cm

STO:
Within 30 minutes of implementing nursing interventions, patient will verbalize gradual reduction of pain from a pain scale of 7/10 to 5/10.
LTO:
Within 2 days of nursing interventions, patient’s occurrence of pain will be prevented.
Independent:

1. Maintain bed rest when patient
experiences abdominal discomfort.
 Reduces metabolic demands and protects the liver.


2. Reduce sodium and fluid intake.
 Minimizes further formation of ascites.

3. Provide comfort measures such as back rub and reposition
 Promotes relaxation, refocuses attention and may enhance coping abilities.
4. Make time to listen to and maintain frequent contact with client.
Helpful in alleviating anxiety and refocusing attention, which can relieve pain.
5. Explain to patient about the importance of paracentesis.
 Removal of fluid to decrease abdominal girth and relieve abdominal discomfort.

6. Instruct to wear non-constricting clothing and avoid frequent contact on the abdomen.
 Constricted clothing and frequent contact on the abdomen stimulates pain sensation
DEPENDENT:
1. Administer omeprazole 40mg once a day 8am as prescribed.
 Covers gastro-intestinal lining which protects from hyperacidity
2. Administer diuretics, (,Furosemide 40mg q6h 8-11-6 , Spironolactone 25mg bid 8-6) as indicated.
 Rapid-acting potent sulfonamide "loop" diuretic and antihypertensive with pharmacologic effects and uses almost identical to those of ethacrynic acid. Exact mode of action not clearly defined; decreases renal vascular resistance and may increase renal blood flow.  Potassium-sparing diuretic; antagonizes aldosterone in the distal tubules, increasing water and sodium excretion EVALUATION STO:
Completely met
After 30 minutes of
implementing nursing
interventions, patient was
able to verbalized gradual reduction of pain from a pain scale of 7/10 to 5/10

LTO
Not met.
Patient’s occurrence of pain was not prevented. Paracentesis was not being performed due to financial constrain

Ineffective breathing pattern related to compression of the diaphragm
Subjective data:
“Lisod kaayo i-ginhawa”,
as verbalized

Objective data:
• flaring of nose
• RR 32 breaths per minute
• Crackles noted on both lower lobes
• O2 sat -92%
• capillary refill- 4 sec
• shortness of breath
STO:
Within 30 minutes of nursing
interventions, the patient will be able to establish effective respiratory pattern.
Independent:

1.Position patient on side lying position
 Facilitates breathing by reducing pressure on the diaphragm and minimizes risk of aspiration of secretions.

2. Conserve patient’s strength by providing rest periods
 Reduces metabolic and oxygen requirements.


3. Change position every 2 hours.
 Promotes expansion and oxygenation of all areas of the lungs

4. Explain effects of wearing restrictive clothing
 Respiratory excursion is not compromised.
5. Encourage slower/deeper respirations, use of pursed-lip technique
 To assist client in ‘taking control’” of the situation
DEPENDENT:

Administer O2 @ 2 l/min as indicated
 To provide adequate oxygen inhalation
STO:
After 30 minutes of nursing
interventions, the patient was able to establish effective respiratory pattern.
LTO
After 2 days of nursing interventions, patient was able to maintain effective respiratory pattern.

Fluid Volume Excess related to fluid shifting from intravascular space to extravascular and intra-abdominal space. Subjective data:
“Punga akong pamati” as
verbalized
Objective data:
• Abdominal girth-
101cm
• Non pitting edema on both lower extremities noted
• Crackles noted upon auscultation on both lower lobes
• Decreased Hematocrit: 35.5% [42-52%]
STO:
Within 30 minutes of nursing
interventions, the patient will be able to understand the importance of compliance to diet modification and fluid restriction.

LTO:
Within 2 days of giving nursing interventions, the
patient will manifest signs of gradual fluid shifting from extravascular and intra-abdominal to intravascular space as evidence by decrease edema and abdominal girth.
Independent:

1. Explain the importance of adhering to low-sodium diet and fluid restrictions.
 Excess sodium leads to water retention, and can increase fluid volume, ascites, and portal hypertension.

2. Provide low sodium diet and restrict fluid.
 Excess sodium leads to water retention, and can increase fluid volume, ascites, and portal hypertension

3. Elevate the both affected lower extremities with one pillow.
 This is to mobilize fluid and to reduce swelling.
. Instruct bedrest. Schedule care with frequent rest periods.
 Limited cardiac reserves result in fatigue. In addition lying down favors diuresis and reduction of edema.

5. Provide safety precautions- use of side rails, bed in low position.
 Fluid shifts may cause cerebral edema/ changes in mentation especially in the geriatric population.

DEPENDENT:
Administer diuretics,(,Furosemide 40mg q6h 5-11-5 , Spironolactone 25mg bid 8-6) as indicated.
 Rapid-acting potent sulfonamide "loop" diuretic and antihypertensive with pharmacologic effects and uses almost identical to those of ethacrynic acid. Exact mode of action not clearly defined; decreases renal vascular resistance and may increase renal blood flow.
 Potassium-sparing diuretic; antagonizes aldosterone in the distal tubules, increasing water and sodium excretion
Administer aminoleban 500cc q12h as prescribed.
 Given to normalize the amino acid, carbohydrates, fats, vitamins and minerals in the plasma.
evaluation STO:
After 30 minutes of nursing
interventions, the patient was able to understand the importance of compliance to diet modification and fluid restriction.
LTO:
After 2 days of giving nursing interventions, the patient manifest no signs of fluid shifting from extravascular and intra-abdominal space to intravascular space as evidence by no decrease in edema and abdominal girth but the patient had a balance intake and output.
Impaired physical mobility related to decreased muscle strength on both lower extremities Objective data:

 Muscle strength: 2/5 on both lower extremities
 Decreased muscle tone on both lower extremities.
 With non-pitting edema on both lower extremities
 Cyanotic nail beds on both lower extremities
 O2 saturation of 93%

STO
After 8 hours of nursing care, patient will be able to:
 Understand the importance of turning on bed and passive range of motion
 Have an increase in muscle strength from 2/5 to 3/5
LTO
At the end of 2 days of giving nursing care, the client will be able to:

 Maintain position of functioning and skin integrity
 Maintain or increase strength and function of affected body part
Independent:

1. Provide regular skin care including pressure area.
To prevent decubitus ulcer

2. Raise side rails.
To provide safety.

3. Assist in turning on bed every 2 hours.
To prevent respiratory complications and pressure ulcers.



4. Encourage participation in self care
 Enhances self-concept and sense of independence.

5. Support affected body parts.
 To maintain position of function and reduce risk of pressure ulcers.

6. Provide passive range of motion on both lower extremities.
 To promote circulation on lower extremities.


evaluation STO
At the end 8 hours minutes of nursing care, patient was able to:
 Understand the importance of turning on bed and passive range of motion
 No change on muscle strength
LTO
After 2 days of giving nursing care, the client was able to:

 Maintain position of functioning and skin integrity

 No increase on muscle strength and function of affected body part
Jan. 26, 2011
Imbalanced Nutrition: Less than Body Requirements related to loss of appetite due to abdominal fullness and discomfort
STO:
Within 8 hours of nursing interventions,
patient will have an increase in appetite
as evidence by increase consumption on food intake.
LTO:
Within 2 days of
nursing interventions,
patient will be able to maintain gradual increase of food intake from about 1/3 to at least 1/2 of share.
Independent:

1. Provide small frequent meals.
 Poor tolerance to larger meals may be due to increased intra-abdominal pressure/ascites.

2. Offer palatable and client’s preferred foods.
 Helps to increase client’s appetite.

3. Limit high-salt foods (e.g., canned soups, processed meats, condiments). Avoid those containing ammonium.
 Salt limitations can help manage fluid complications in cirrhosis (e.g., ascites or tissue edema). Ammonia potentiates risk of encephalopathy.

4. Restrict intake of caffeine, gas-producing or spicy and excessively hot or cold foods.
 Aids in reducing gastric restrictions and abdominal discomfort that may impair oral intake/ digestion

5. Provide frequent mouth care
 Client is prone to sore or bleeding gums and bad taste in mouth.


DEPENDENT:
1. Administer multivitamins such as
• Essentiale forte 1capsule tid 8-1-6
 It activates metabolic function and supports the energy balance of the liver. It restores enzyme functions and promotes detoxification of the liver. Neutral fats and cholesterol are transformed into transportable forms and led to their physiological oxidation. Liver cell regeneration is stimulated and the bile is stabilized •
Administer aminoleban 500cc q12h
 Because of their peculiar role in whole-body nitrogen metabolism and the competitive actionon amino acid transport across the blood–brainbarrier, branched-chain amino acids (BCAAs) have been extensively used in subjects with liver disease to preserve or to restore muscle mass and to improve hepatic encephalopathy.
 Given to normalize the amino acid, carbohydrates, fats, vitamins and minerals in the plasma.
evaluation
STO:
After 8 hours of
nursing interventions, patient had an increased appetite as evidence by increase consumption on food intake.

LTO:
After 2 days of
nursing interventions, patient had a gradual increase of food intake from about 1/3 to at least 1/2 of share.
Risk for Impaired skin integrity Feb 02, 2011
Risk factors :
• Patient is unable to ambulate
• Bulging abdomen
• Unable to turn to sides on his own
• Muscle grading: 2/5 in both lower extremities.

STO:
Within 8 hours of nursing intervention, patient will be free or prevent skin breakdown.
LTO
Within 2 days of nursing interventions, patient will be able to maintain skin integrity.
INDEPENDENT:

1. Turn the patient to sides every 2 hours
To prevent development of pressure ulcers
2. Keep linens dry and free of wrinkles
Moisture aggravates pruritus and increases risk of skin breakdown.
3. Provide skin care to prevent pressure in bony prominences by cushioning it with a pillow or with waterfilled-gloves.
Reduces pressure on susceptible areas, prevents skin breakdown.
4. Provide massage and active/passive ROM and stretching exercises on a regular schedule.
 Prevents problems associated with muscle pain, dysfunction and disuse. Helps maintain muscle tone/strength and joint mobility and proper body alignment. Decreases spasticity and its effects and reduces risk of loss of calcium from bones
5. Apply lotion such as moisturizer
 To prevent dryness of the skin.
6. Perform hand washing before and after caring the patient.
 To deter spread of microorganisms
STO:
After 8 hours of nursing interventions, the patient showed no signs of skin breakdown and developing pressure ulcers.
evaluation LTO
After 2 days of nursing interventions, patient was able to maintain skin integrity.
DISCHARGE PLAN Medication There were no home medications that were prescribed by the patient’s doctor because his significant others signed the HAMA or home against medical advise and the doctor advised him to go home because his disease has a poor prognosis. In addition, the patient’s chart and discharge summary form doesn’t have any home medications ordered by the doctor. Exercise  Gradual increase in exercise pattern based on patient’s tolerance.
 Emphasize passive range of motion exercise to prevent immobilization and to promote proper venous circulation
Gradual increase in exercise pattern based on patient’s tolerance.
Emphasize passive range of motion exercise to prevent immobilization and to promote proper venous circulation Promote the importance of rest, relaxation and conservation of energy to relief physical and psychological stress.
 Preventing further damage. It is important to stop consuming alcohol which is one of the biggest damage contributors to the liver.
 Stress the importance of consumption of drugs and it should be monitored to prevent severity of the disease.
Health teachings  Explain to the significant others with emphasis on:
a. Proper nutrition
b. Proper hygiene
c. Decrease fluid intake to prevent further ascites and edema
d. Decrease intake of foods high in sodium to prevent fluid retention.
e. Avoidance of giving non-steroidal inflammatory disease without doctor’s prescription for it will cause further liver damage.
 Avoidance of strenuous activities.
 Keep back clean and dry to prevent any complications especially respiratory complications and Decubitus Ulcer.
 Place patient in a comfortable position as tolerated.
 Provide a safe environment free from injuries to prevent bleeding and further trauma to patient.
Out Patient  Encourage the significant others to let the patient see his doctor for any more problems still.
 Encourage also the significant others to refer the patient immediately to hospital if there are any unexpected health problems that will occur.
Diet  Instruct the significant others to avoid fatty foods such as pork.
 Avoid high sodium foods such as noodles, canned goods and all processed foods to prevent retention of fluid in the patient’s body.
 Avoidance of foods containing protein because it is a source of the toxic compounds that cause hepatic encephalopathy.
Spiritual:  Encourage prayer for the recovery of the patient.
 Encourage the significant others to anoint the sick patient to promote spiritual wellness.
LEARNING EXPERIENCE Things were learned and discovered while making this requirement a successful one. And basically, our group learned a lot from this duty especially to our clinical instructor. And through that experience, different views and perspectives were raised to have it more comprehensive. Indeed, experience has always been the best teacher. This case study and hospital exposure are some proofs that the life of a nursing student is never easy. But our eagerness and passion to have a successful nursing career enable us to move on and face the many challenges in the study of nursing. Through that experience we were able to realize that being a Health Care Provider is not easy. We need to understand each situation that the individuals are having. Every single step that we made must be true, understandable and with passion. And from the steps that we had made, we are ought to become responsible in a way that we serve people especially the patients were taking for in a simpliest way As a result, we have learned the nature of the disease. These things that we have learned will be useful when we become professional nurses someday. We are very grateful to
our clinical instructor Mr. Rick Wilson Bunao, RN, MN for giving us the chance to study this case. Through his guidance, we were able to implement our interventions successfully. Lastly, but never has been the least,
we thank God for the many blessings,
especially the gift of good and healthy lives. -thank you-
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