case study on liver cirrhosis

1. OObbjjeeccttiivveess ooff CCaassee ssttuuddyy
 TToo ggaaiinn iinn--ddeepptthh kknnoowwlleeddggee aabboouutt tthhee ssttuuddyy ssuubbjjeecctt//ddiisseeaassee
ccoonnddiittiioonn..
 TToo ggaaiinn tthhee ccoonnffiiddeennccee iinn hhaannddlliinngg ssuucchh ccaasseess iinn ffuuttuurree..
 TToo ffuullffiillll tthhee ppaarrttiiaall ccoouurrssee oobbjjeeccttiivvee ooff MM..NN.. ccuurrrriiccuulluumm..
 To share experience and knowledge to friends,juniors and seniors.
Rational for the selection of case
 Cirrhosis is ranked as the 9th leading cause of death in the united state and 4th leading
cause of death in person between 35 and 45 years of life.
 Excessive alcohol injection is the single most common cause of cirrhosis and
alcoholism is common in Nepalese society, that’s why it is the interesting case for
study so, I select this case.
A CASE STUDY ON CIRRHOSIS OF LIVER
Health History:
A: Bio-graphicalData:
Patient’s Name : - Mrs. Thumi Sara Marsagni
Age/ sex :-75 yrs/female
Marital status : - Married
Education : - Literate
Occupation : - Agriculture
Religion : - Hind
Address :- Nawalparasi, Gaidakot ,1
Ward :- Female Medical Ward
Bed No. : - 31
IP No. :- 45697
Date of admission :- 2068/07/13
Provisional Diagnosis:- Cirrhosis of Liver
Interview date :- 2068/07/14
Date of discharge :- 2068/07/18

2. Final Diagnosis :- Cirrhosis of Liver
Attending physician :-
Informants Obtained From :- Patient (self)& his son
B : Chief complain
 Abdominaldistention since 15-16 days
 Bilateral pedal swelling since 10-12 days
 Moderate shortness of breathing since 5-7 days
 Loss of appetite since 15-16 days
C. PresentIllness/Health Status
1. Summaryof Presentillness;
Mrs . Thumisara was absolutely fine before 17monts back. Gradually she
developedthe problems ofabdominal distension,swelling of lower legs and
mild to moderate shortness of breathing, so her family members tookher in
medical shop near by her home and she was referred to hospital for further
management . at that time she attained the medical OPD and cirrhosis of
liver was diagnosed and advised to take oral medicines and stop of alcohol
. Her condition was gradually improved.
Thumisara again started to take alcohol since 6-7 months and the problem
was relapsed again and she was admitted.
2. Investigationof symptom
symptoms onset character duration Alleviating
factors
Aggravating
factor
Abdominal
distention
15-
16days
moderate _ _ While
taking more
fluids and
alcohol
Bilateral
pedal
swelling
since
10-12
days
moderate _ _ _

3. shortness
of
breathing
5-7
days
Mild to
moderate
_ Abdominal
distention
Resting in
upright
position
Loss of
appetite
since
15-16
days
moderate _ _ _
D.Past Illness:
Childhood Illness Adult Illness
2) Injuries andAccidents: My patient had no any history of external injuries and
accidents.
3) Hospitalization, Operations or Special Treatment: she had no history of
previous hospitalization , but she had treated in OPD with same problembefore 17
months.
4) Allergies:-According to my patient she has not known allergies to any food,
Drugs and others
Diseases yes No Disease Yes No
Measles  Hypertension 
Mumps  Heart disease 
Whooping
cough
 Tuberculosis 
Polio  Diabetes 
Rheumatic
Fever
 Filariasis 
Tuberculosis  Malaria 
Malnutrition  Cancer 
operation  Asthma 
Others Accidents 
Others 

4. 5) MedicationTakenat Home :- She uses to takes some home remedy like
Juwano, ginger , besar , marcha for some common health problem.
6) Traditional Healer’s Prescription: According to my patient, sometimes shealso
used to take the Traditional Healer’s prescriptions for her and her family’s health
problems.
7) Medical Practioner’s prescription:- According to my patient, she takes medical
practioner’s prescription for his health problem.
8)Self prescription:My patient useto take some common medicines like ,
paracetamol, Decold , Diagen in her family members’ prescription whenever she
has problem like headache ,fever , common cold , etc. but they doesn’tknow the
drug doses, it’s side effect ,indication and contraindications etc.
Family History
1)
No. of children Age(year) Health Status
Krishna Bahadur
Marsagni
48 years Healthy
Pashupati Marsangi 46 years Healthy
Drupati Marsangi 42 years Healthy
Dol Kumari Marsangi 39 years Healthy
Bharat Marsangi 37 years Healthy
2) History of Any of the Disease belowinMother’s andFather’s Family
Disease Father’s Family Mother’s
Family
Remarks
yes No yes No
Hypertension  
Diabetes  
Cancer  
Blood disorder  
Asthma  
Cardiovascular
problems
 
Arthritis/Gout  

5. Tuberculosis  
Other specify  
FAMILY TREE
F. Psychological:
a) Client’s Reaction to illness:
Mrs . Thumisara, has normalreaction to her illness .
b) Client’s Coping Pattern:
she is using her pastexperiences of illness, other life experiences and supportfrom
the family, relatives as well as health person as coping pattern.
c) Client’s Value of Health:
she thinks that health is very essential for young age but have to maintain for
lifelong as we can.
d) Client’s Perception of the Care Giver:
she thinks that all health care provider arevery kind.
75
years
42
yrs
yrsyr
s
48
yrs
37
yrs
46
yrs
39
yrs

6. G. Sociological:
a) Family Relationship:
Client’s Position in the Family: she is the eldest person of the family.
Person Living With Client (SupportSystem) : Her Family Members (sons ,daughters
granddaughter and grandsons.
Recent Family Crisis or Changes: according to informant, they have difficultin
managing the time for their sick mother because they have to go for work and
study.
B) OccupationalHistory:
PresentJob: sheis very old ,so she cannot do any work.
.
c) Educational Level:
Highest Degreeor Grade Attended: illiterate
Level of Learning: illiterate)
Cultural:
Ethnic Group: Magar
Client’sBeliefsabout Health and Illness: Her beliefs that the illness is caused by
the unhappiness by god.
Client’s HealthPractice: According to she, she don’thave any idea for good health
practice
Sources of Care(Modern/traditional): According to her and her informant ,
sometimes they goes to traditional healer , sometimes they goes to local medical
shop and health post as well as Hospital for health seeking.
e) Leisure Time Activities: shespends her time with her grandsons and grand-
daughters
f) Chemical Use (type, frequency, problems relatedtouse)
Cigarettes: smoker. Shetakes 3-4 sticks /day
Substances (e.g. Hashish, bidi, etc):- Non –user
Alcohol: shetakes alcohol every day about 800-1000ml.
H. Environmental History:

7. a) Type of Drainage System: Open
b) Types of Toilet Used: Water seal
c) Sources of drinking Water: Tap water (unboiled water)
) KitchenStyle: Separate kitchen
e) Types of Fuel Usedin Cooking: Fire-Wood
I. Significant DevelopmentTask
a) Past if Relevant…………………………………………………………
b)Current inTerms Of Appropriate Task For Age…………..
………………………………………………………………………………….
Developmentaltasks of older adulthood
S.N. According to
book
According to patient
1 Adjusting to
decreasing health
and physical
strength
 My patient is adjusting her
decreasing health and physical
strength as she is depending on
stick while walking .
 As she is older she cannot do
household work so she is
depending to her family members
for her activities of daily living
 She is accepting her decrease
health and physical strength as
normal phenomena.
2 Adjusting to
reduced or fixed
income
 My patient has no fixed income so
she is economically fully depending
to her family members .
3 Adjusting to death
of spouse
 Mrs. Thumisara has already lost her
husband for 10 years so she is
adjusting to death of spouse
4 Accepting oneself
as an aging person
 Mrs. Thumisara has full awareness
that she is very old and she accepts
oneself as an aging personso she

8. handed over her kingship to her son
and daughter- in law
5 Maintaining
satisfactory living
arrangements
 Mrs. Thumisara has not maintained
her own satisfactoryliving
arrangement because she is non job
holder women however she is
satisfied whatever she has now.
6 Redefining
relationships with
adult children.
 My patient redefining relationship
with adult children as she is still
honorable in her family as a head of
family so she gives her valuable
advice and suggestionto her family
as needed.
7 Finding meaning in
life.
 My patient is accepting the god’s
natural phenomena towards the
living creature and realizing that she
fulfilled her female role sincerely.

9. Physical Examination
S.N HealthHistory (Subjective
Data)
Ye
s
No Physical Examination
(objective Data)
1 General
Cognation(Limitation/Restricti
on)
Sensation(Limitation/Restricti
on)
Communication(Limitation/Re
striction
General
Gait: Imbalanced
Facial Expression (grimacing): undifferentiated
Level of consciousness: Conscious
Orientation to time ,place and person: fully
oriented
Measurements
Height: 4feet 6 inch
Weight :37 kg
Temperature : 98°C
Pulse:90 b/min
Respiration:20 /min
Bloodpressure : 110/60 mmof hg
2 ProblemrelatedtoHeadand
face
Headache
Injury
Puffiness of face
Hair :black and grey in colour
Scalp: dirty, dandruff present, no injury, lumps
and other lesions present
Skull: normalin shape
Face:uniformmovement of side of face , slight
edema ,no masses
Sinuses : No swelling , tenderness and
depression

10. 3 ProblemRelatedtoEye/
Vision
Pain
Swelling
Discharge
Excessive tears
Difficulty Seeing at Night
Any other
problems……………………
Conditionof Eyelids: No swelling, redness
,lesions
Conditionof Conjunctiva: pale palpebral
conjunctivas, Conditionof cornea:transparent
Colour of Sclera: yellow sclera
Pupil Size Symmetry: uniformin size and shape
Reactiontolight : reactive to light
Discharge fromeyes : slightly white sticky
discharge
Visual Acuity: Sub- Normal
Eye Glasses : Not used
4 ProblemRelatedtoEar:
Pain
Tinnitus
Vertigo
Dizziness
Others …………………..
Conditionof External Ear:
Normally Located external Ear
Drainage from Ear: No dischargeof pus , blood
,slightly wax present
Lumps or Lesions: Notfound
Ear Drum:
Hearing Aid: Not used
Rinne Test: AC>BC
Weber Test: AC>BC
5 Problems RelatedtoNose
Injury
Bleeding /Discharge
Blockage
Location: centrally located
Nasal Deviation: Not found
Bleeding: No
Patency of the Nostrils: patented
Any Discharge: Not found
Smell:No problem in smelling
Conditionof Nasal mucosa:
Pale in colour
Flaring Nostrils: Notpresented.
Inflammation: Not found.
Nasal Polyps: Not found

11. 6 Problems RelatedtoMouth
Sore on Lips
Sore on Tongue
Gum Bleeding
Missing Teeth/Dentures
Change inTaste
Toothache
Lips:Dry
Oral Cavity: Pale mucous membraneof oral
cavity
Teeth: Missing all teeth
Tongue: slightly dry and coated tongue
Vocal cord, Uvula and Tonsils: Not enlarged and
inflamed.
7 Problems RelatedtoSpeech
Loss of Consciousness
Loss of Memory
Convulsion
SpeechDisorders: Notpresented.
8 Throat and Neck
Difficulty nSwallowing
Problems inTonsil
Neck Rigidity
Location: centrally located, no tilting of head
Movement : Full and smooth range of
movement, no stiffness or tenderness
Jugular Vein: Not enlarged
Conditionof Thyroid: No enlargement of
thyroid gland
ProblemRelatedto
Respiration:
Dyspnoea
Cough
Hoarseness of Voice
Cyanosis
Others………………………………..
Respiratory Rat:20 b/min
Depthof respiration: Normaldepth
Quality of Respiration :dyspnoea in lying
position
Chest Inspection
- lateral diameter is wider than anterior
posterior diameter
- sternumis located at the midline
- Even expansion of the chestduring
breathing
No intercostals retraction
• Slight cough , but no productive
sputum.
Chest Palpation

12. 10
11
Heart and Circulation:
Chest pain
Numbness
Palpitation
Fever , chills
Bleeding tendencies
Others
:……………………………………………
……………………………………………
Nutrition/Hydration:
Anorexia
Nausea/ Vomiting
Unusualthirst or hunger
Diaphoresis
Non Vegetarian
Special Diet
Food Dislikes
Ability to Chew or swallow
- No tenderness, lump or depression along
the ribs.
Percussion
- Deep resonantsound heard all over the
lungs.
Auscultation
- Breath sounds areheard in all areas of the
lungs.
- Inspiration longer than expiration
- No , rhonchi, wheezing sound was
presented
Pulse Rate: Radical: 88b/min Apical: 88
b/min
Character of Pulse: Normal
Blood Pressure: Right110/60mmof hg
Left: 100/60 mmof hg
Peripheral Pulse: All present
Capillary Refill: 1 second
Edema ( e.g. puffy eye) : present
Varicosities: Absent
Visible External Jugular veins : Absent
Systolic or Diastolic Murmur : Absent
Body Build: Average
Body weight : 37 kg
Skin Turgor/Elasticity : Normal
Condition of Buccal mucosa : intact

13. 12
13
Resent change in Weight
Eliminationand
reproduction:
Pain in Urination
Change in urine colour
Urinary Retention
Frequency of Urination
Incontinenceof Urine
Constipation
Diarrhea
Passing worms, Mucous
Eliminationand
Reproduction:
Appearanceof Stool
Bleeding fromRectum
Flatulence
Heart Burn
Abdominal Pain
Dischargefrom Genitalia
Pain or Swelling of scrotum
Any Unexpected vaginal
bleeding
Any menstrual Disorder
Uterine prolapsed
Knowledgeof family planning
method
Family Planning Device Used
Appearanceof Urine : yellowish (concentrated)
Appearanceof Stool: Normal
Any Enlargement of Liver, spleen: moderately
enlarged liver found.
Any Masses in Abdomen: Not Found
Any tenderness in AboveAres: Tenderness in Rt.
Hypocardium
Size and shape of abdomen: distended
abdomen
Shifting dullness: present
Distendedabdominal veins :slightly
Fluidthrill:present
Abdominal girth: 33 inch
Enlarges Inguinaland femoralNodes: Not found
Bowel sounds: Present
Lesion or tumors of Rectal Area: Not found
Abnormalities of Genito-Urinary Area: Not
found
Female- Rectocele and Cystocele: not present
Uterine prolapsed : not present
Discharge : Not present
Other………………………
………………….

14. 14
15
Bowel Habits:
Regular/ Irregular
Pap Smear Test Done
Mobility :
Difficulty with Ambulation
Muscle cramping or
Weakness
Muscle Pain
Back Pain
Joint Pain or Swelling
Limited Joint Movement
Ability to Do ADLS
Comfort ,Sleepand Rest:
Pain
Regular Sleep Pattern
Integumentary Hygiene :
Non –healing sores
Change in Mole Colour
Nail Changes
Itching Of Skin Sensation
Regular bathing Habit
Motor Strength and Mobility: slight reduced
Enlargement and Stiffness of Joints: Not present
Contractures: slightly Present( knee joint)
Spinal Deformity: Not Present
Range of motion Exercise: Cannot move in full
Range Of Motion
CANE: use of stick Crutches : Not used
Walker : Not used Prosthesis : Not Used
Location Of Pain : Rt. Hypochondrium
tenderness
Discomfortdueto abdominal distention
Sleep disturb at night
Colour of skin, Texture, Turgor : Normal
Pigmentation, Lesion, Tumors: Not found
Skin Inflammation : Not present
Edema: present(lower legs and abdomen)
Rashes : Not present
AbnormalNail Conditions: Not present
Distribution and Texture of Hair : equally
distributed of scalp hair, no,any abnormally
distribution in body hair , the texture of hair is
soft
Touch Sensation: Normally Presented all over
the body
Enlarged lymph Glands and nodes: Not found

15. 16 Reflexes
Biceps Reflex: present
Brachilo radialis: present
Triceps Reflex: present
Patellar Reflex : present
Achilles Reflex: present
BabinskiReflex : present( negative)
Kerning’s sign : Absent
UNIT II - INTRODUCTION TO DISEASE
Cirrhosis of liver
Introduction
• The termcirrhosis was first usedby Rene Laennec (1781-1826) todescribe
the abnormal liver color of individuals withalcohol inducedliver disease.
• DerivedfromGreek word Kirrhosmeans Yellowish –brown color.
Definition:
• Cirrhosis is achronic progressive disease of the liver characterizedby
extensivedegenerationanddestructionof the liver parenchymal cells.

16. • Cirrhosis is achronic disease characterizedby replacement of normal liver
tissue withdiffuse fibrosisthat disrupts the structure and functionof the
liver.
• The liver cells attempt toregenerate, but the regenerative process is
disorganized, resulting inabnormal bloodvessels andbile duct
architecture.
• The liver slowly deteriorates andmalfunctions due tochronic injury. Scar
tissue replaceshealthy livertissue, partially blocking the flowof blood
throughthe liver.
Scarring also impairs the liver's ability to:
• control infections
• remove bacteriaandtoxins from the blood
• process nutrients, hormones, anddrugs
• make proteins that regulate bloodclotting
• produce bile tohelp absorbfats—including cholesterol—andfat-soluble
vitamins
Incidence:
• It is the twelfthleading cause of death, 27,000 deaths eachyear and
affects menslightly more thanwomen.
• It is the 10th
leading cause of deathin the US, with mortality rate of 9.2
deaths per 100,000 populations.
• Of those deaths, 45% were alcohol related. Menare more likely than
women to have alcoholic cirrhosis.

17. • Worldwide, post necrotic cirrhosis is the most commonin women.
Mortality is higher fromall types of cirrhosis inmenand non whites.
CAUSES OF CIRRHOSIS
 Alcohol
 Chronic viral hepatitis (B or C) Non-alcoholic fatty liver disease
 Immune
o Primary sclerosing cholangitis
o Autoimmune liver disease
 Biliary
o Primary biliary cirrhosis
o Cystic fibrosis
 Genetic
o Haemochromatosis
o α1-antitrypsin deficiency
o Wilson's disease
 Cryptogenic (unknown)
Etiology:
Alcohol.
• Heavy alcoholfor severalyears cancause chronic injury to the liver and
damages.
• For women, consuming two to three drinks—including beer and wine per
day and for men, three to four drinks per day, can lead to liver damage and
cirrhosis.
• A common problem in alcoholic is protein malnutrition.
Obesity:
WHO ,2008, estimatedthat more than 200 million men and close to 300
million womenwere obese, obesityis a common cause of chronic liver
disease , 17% of liver cirrhosis is attributable to excess bodyweight.
Chronic hepatitis C.

18. Chronic hepatitis C causes inflammation and damage to the liver over time
that can leadto cirrhosis and approximately 20% patient will develop
cirrhosis.
Chronic hepatitis B and D.
• Hepatitis B and D is virus that infects the liver and canlead to cirrhosis,
but it occurs only in people who already have hepatitis B. approximate
10%- 20% will develop cirrhosis.
Nonalcoholic fattyliver disease (NAFLD).
• This is associatedwith obesity, diabetes, protein malnutrition, coronary
artery disease, and corticosteroidmedications.
• Autoimmune hepatitis. It is causedby the body's immune systemattacking
liver cells and causing inflammation, damage, and eventually cirrhosis.
Genetic factors –
About 70 percent of those with autoimmune hepatitis are female.
Diseasesthat damage or destroy bile ducts.
• Severaldifferent diseases(cholangitis)candamage or destroy the ducts that
carry bile from the liver, causing bile to back up in the liver and leading to
cirrhosis.
Inherited diseases.
• Cystic fibrosis, alpha-1 antitrypsin deficiency, hemochromatosis, Wilson
disease, galactosemia, andglycogenstoragediseasesare inherited diseases
that interfere the liver function properly, Cirrhosis canresult.
Drugs, toxins, and infections.
• Drug reactions(Acetaminophen, isonazide, methotrexate) prolonged
exposure to toxic chemicals, parasitic infections, and repeatedbouts of heart
failure with liver congestion.
Types of cirrhosis :

19. Alcoholic (historically called Laennec’s cirrhosis)cirrhosis:
• Also calledmicro nodular or portal cirrhosis and usually associatedwith
alcoholabuse.
• The first change in the liver from excessive intake is an accumulation of fat
in the liver cells;uncomplicated fatty changes in the liver are potentially
reversible if the person stops drinking alcohol.
If the alcoholabuse continues, widespreadscarformation occurs
throughout the liver.
Postnecrotic cirrhosis(macro nodular):
• Mostcommon worldwide, massive loss of liver cells with irregular patterns
of regenerating cells due to complication of viral, toxic or idiopathic
(autoimmune) hepatitis.
Billiary cirrhosis: is associatedwith chronic billiary obstructionand
infection. There is diffuse fibrosis of the liver with jaundice.
Cardiac cirrhosis:chronic liver disease results from long-standing, severe
right side heart failure with corpulmonale, constrictive pericarditis, and
tricuspid insufficiency.
Pathophysiology:
Liver insult, alcoholingestion, viral hepatitis, exposure to toxin
Hepatocyte damage
Liver inflammation - ↑WBCs, nausea, vomiting, pain , fever, anorexia,
fatigue
Alteration in blood and lymph flow
• Liver necrosis →liver fibrosis and scarring → portal hypertension
- ascities, edema,

20. - spleenomegaly(Anemia,
thrombocytopenia, leucopenia)
- Varices (esophagealvarices, hemorrhoids.)
↓ billirubin metabolism – hyperbilirubinemia, jaundice
• ↓ bile in gastrointestinaltract – light coloredstool
• ↑ urobilinogen – Dark Urine
• ↓ vit K absorption- bleeding tendency
• ↓ metabolism of protein, carbohydrate, fats→ hypoglycemia,
• ↓ plasma protein- ascites andedema
↓androgenand estrogendetoxification(↓ hormone metabolism)- ↑ estrogen
and androgens hormone – Gynecomastia,loss ofbody hair, menstrual
dysfunction, spider angioma, palmer erythema, testicularatrophy
• ↓ ADH and aldesterone detoxificationso ↑ ADH levels - edema
• Biochemicalalteration- ↑ AST, ALT levels, ↑ bilirubin, low serum albumin,
prolong prothombin time, elevatedalkaline phosphatase.
• Liver failure
• Hepatic encephalopathy
• Hepatic coma
• Death
Clinical manifestations:
Earlymanifestations –
 No symptoms in the early stages ofthe disease.
 GI disturbances are more common , anorexia, dyspepsia, flatulence,
weakness,fatigue, nausea, vomiting, weightloss, abdominal pain and
bloating, and change in bowel habit ( diarrhea, constipation).
 Abdominal pain, dull and heavy feeling in right upper quadrant or
epigastric due to swelling and stretching of the liver capsule, spasmof
biliary duct.
 Fever, lassitude, weightloss, enlargementof liver and spleen.

21. Later manifestations:
May be severe and result from liver failure and portal hypertension.
 Jaundice, peripheral edema and ascities developgradually.
 Other late symptoms include skin lesion, hematologicaldisorders, endocrine
disturbances, and peripheral neuropathy.
 In the advancedstage the liver becomes smalland nodular.
Jaundice:
 It results from the functional derangementof liver cells and compressionof
bile duct by connective tissue overgrowth.
 Jaundice occurs as a result of decreasedability to conjugate and excrete
bilirubin.
 If obstruction of the biliary tract occurs, obstructive jaundice may also
occurand usually accompaniedby pruritus.
Skin lesion:
 Spider angioma ( telangiectasia orspidernavi) are small dilated blood
vessels with a bright red centerpoint and spider like branches occurs in
nose, cheeks,upper trunk, neck and shoulders.
 Palmererythema, a red area that blanches with pressure, is locatedon the
palm of the hand.
 Both lesions are due to increase estrogenin blood as a result of the damaged
liver’s inability to metabolized steroid hormone.
Hematologic problem:
 Thrombocytopenia, leucopenia, anemia, due to spleenomegaly(back flow of
blood from portal vein into the spleen.)
 Anemia due to inadequate RBC production and survival, and due to poor
diet, poor absorption and bleeding from varices.
 Coagulationproblems result from the liver’s inability to produce
prothrombin and blood clotting and manifested by hemorrhagic phenomena
or bleeding tendencies e.g. epistaxis, purpura, gingival bleeding, heavy
menstrual flow.
Endocrine problem:

22.  In men, Gynecomastia, lossofaxillary and pubic hair, testicularatrophy
and impotence with loss of libido due to increasedestrogenlevel.
 In younger female, amenorrhea may occurand in older, bleeding may
occur.
 ↑aldosterone hormone may cause sodium waterretention and potassium
loss.
Peripheral neuropathy:
 Probably due to dietary deficiencyof thiamine, folic acid and cobalamin.
Clinical manifestations:
According to book According to patient
Compensated
• Intermittent mild fever
• Vascular spiders
• Palmar erythema (reddened
palms)
• Unexplained epistaxis
• Ankle edema
• Vague morning indigestion
• Flatulent dyspepsia
• Abdominal pain
• Firm, enlarged liver
• Splenomegaly
Decompensate
• Ascites
• Jaundice
• Weakness
 Hepatomegaly
 Jaundice (bilirubin total 2.2 mg /dl)
 Moderate Ascites
 Bilateral pedal edema
 Losses of appetite
 Abdominal pain
 dull and heavy feeling in right upper
quadrant
 weakness, fatigue, nausea, weight
loss
 Anemia (pale mucosa,)
 Mild shortness of breathing
• Ascites
• Jaundice
• Weight loss

23. • Muscle wasting
• Weight loss
• Continuous mild fever
• Clubbing of fingers
• Purpura (due to decreased
platelet count)
• Spontaneous bruising
• Epistaxis
• Hypotension
• Sparsebodyhair
• White nails
• Gonadal atrophy
Diagnosisaccording to book
• Liver function test : ↑alkaline phosphate, ALT,AST and y – glutamyl
transpeptidase ( GGT)
• Bloodtest: ↓ total protein, ↓ albumin, ↑ serum bilirubin and glubomin
• Prothombin time is prolong
• Liver cell biopsy to identify liver cellchanges
• Ascites fluid test
• Liver ultrasound
• CT Scan
• Stoolfor occultblood
Endoscopy
Investigations
These are performed to assess the severity and type of liver disease.
Severity
■ Liver function.Serum albumin and prothrombin time are the best indicators
of liver function: the outlook is poor with an albumin level below 28 g/L. The
prothrombin time is prolonged commensurate with the severity of the liver
disease .
■ Liver biochemistry.This can be normal, depending on the severity of
cirrhosis. In mostcases there is at least a slight elevation in the serum ALP

24. and serum aminotransferases.In decompensatedcirrhosis all
biochemistryis deranged.
■ Serum electrolytes.A low sodium indicates severe liver disease due to a
defectin free water clearance or to excess diuretic therapy.
■ Serum creatinine.An elevated concentration 130 mol/ L is a marker of
worse prognosis.Inaddition, serum -fetoproteinif 200 ng/mL is strongly
suggestive of the presence of a hepatocellular carcinoma.
Ultrasound examination. This can demonstrate changes in size and shape of the liver.
Fatty change and fibrosis produce a diffuse increased echogenicity. In
established cirrhosis there may be marginal nodularity of the liver surface and distortion of
the arterial vascular architecture. The patency of the portal and hepatic
veins can be evaluated. It is useful in detecting hepatocellular carcinoma. Elastography is
being used in diagnosis and follow-up to avoid liver biopsy.
■ CT scan
Arterial phase-contrast-enhanced scans are useful in the detection of hepatocellular
carcinoma.
■ Endoscopy is performed for the detection and treatment of varices, and portal
hypertensive gastropathy. Colonoscopy is occasionally performed for
colopathy.
■ MRI scan. This is useful in the diagnosis of benign tumours such as haemangiomas. MR
angiography can demonstrate the vascular anatomy and MR cholangiography the biliary
tree.
Liver biopsy
This is usually necessary to confirm the severity and type of liver disease. The core of liver
often fragments and sampling errors may occur in macronodular cirrhosis. Special stains are
required for iron and copper, and various immunocytochemical stains can identify viruses,
bile ducts and angiogenic structures. Chemical measurement of iron and copper is
necessary to confirm diagnosis of iron overload or Wilson’s disease. Adequate samples in
terms of length and number of complete portal tracts are necessary for diagnosis and for
staging/grading of chronic viral hepatitis.
Diagnostic Investigations in patient
According to Book According to Patient

25. • Liver function test :
↑alkaline phosphate,
ALT,AST and y –
glutamyl transpeptidase (
GGT)
• Bloodtest: ↓ total protein,
↓ albumin, ↑ serum
bilirubin and glubomin
• Prothombin time is
prolong
• Liver cell biopsy to
identify liver cellchanges
• Ascites fluid test
• Liver ultrasound
• CT Scan
•
 Liver function test :
SGOT/AST : 187 U/L
SGPT/ALT: 88.0 U/L
Alkaline Phosphate: 124 IU/L
 Totalprotein : 6.4 gm/dl
 Albumin : 3.4 gm/dl
 Prothombin time: 23.3 sec
 INR : 1.8
 Bilirubin Total: 2.2mg/dl
 Creatinine : 2.0 mg /dl
 Haemoglobin: 7.8 gm/dl
 WBC : 11,600Mm3
 Platelets : 61,000Mm3
 USG: findings s/o cirrhosis of
Liver, Moderate Ascites
Others Investigations of patient
Date of
investigation
According to my patient Normal range
2068/07/13 Hematology
Hb :7.8gm /dl
WBC:11,600 mm3
Platelets :61,000 mm3
ProthombinTime (test):
23.3sec
ProthombinTime (control):
14.0 sec
INR : 1.8
Differentialcount
Neutrophil- 90%
Lymphocyte 10%
Esinophil-00
Basophil-00
HB% M-13-15 F-12-14
gm/dl
WBC-400O-1100mm3
Platelets 1,50,000-
4,00,000
Prothombin Time (test)
14-16 sec
Neutrophil-40-70%
Lymphocyte-30-35%
Esinophil -1-2%
Basophil-0-1%

26. 2068/07/16
Biochemistry-report
Blood sugar (R):129.0 mg/dl
Creatinine: 2mg/dl
Sodium : 142.7mmol/l
Potassium :3.45 mmol/l
Total Protein : 6.4 gm/dl
Albumin: 3.4 gm/dl
SGOT/AST: 187.0 U/L
AGPT/ALT:88.0 U/L
Alkaline phosphates:124.0
IU /L
Blood grouping:’’B’’
positive
Bilirubin Total: 2.2 mg/dl
Bilirubin Total: 0.8 mg /dl
ECG : Normal Sinus
rhythm, non specificT wave
abnormality
Urine RE/ME
Colour-light yellow
Reaction –Acidic
Albumin- Nil
Sugar-Nil
transparency-Clear
Pus Cell-2-4 /HPF
RBCs: Plenty
Epithelialcells- 3-4 /HPF
USG abdomen and pelvis:
Finding S/O Cirrhosis of
Liver
Moderate Ascites
Blood sugar (R): 60-180
mg/dl
Creatinine: 0.4-1.4 mg/dl
Sodium : 135-150 mmol/L
Potassium : 3.3-5.5
mmol/L
Total Protein :6-8 gm/dl
Albumin: 3.5-5.5 gm/dl
SGOT/AST: M ˂37 F ˂31
U/L
AGPT/ALT ˂40.0 U/L
Alkaline phosphates : M-
64 -306 F: 84-306
Up to 15 yrs: <644
Up to 17 yrs : <483
Bilirubin Total: 0.4-1.0
mg/dl
Bilirubin Total: 0.1-0.4
ECG : Sinus rhythm
Urine R/E:Acidic
Appearance:Clear
Color: P. yellow
WBC:3-5/HPF
Epithelial cell: 2-4/HPF
USG abdomen and
pelvis: Normal scan

27. 068/07/17
Creatinine: 1.7 mg/dl
Platelets :67,000 mm3
Hb : 10.2 gm /dl
Platelets :92,000 mm3
Creatinine: 0.4-1.4 mg/dl
Platelets 1,50,000-
4,00,000 mm3
Management (According To Book)
Medicalmanagement
• Monitor for complications: Ascites, bleeding esophagealvarices andhepatic
encephalopathyand if occurs manage them accordingly.
• Many medicines have been studied, such as steroids, penicillamine
(Cuprimine, Depen), and an anti-inflammatory agent (colchicine), but they
have not been shownto prolong survival or improve survival rate.
• Researchersare studying various experimental treatments for cirrhosis.

28. Surgicalmanagement
• The only surgery that has been proven to improve the chances oflong-term
survival is liver transplantation.
• About 80-90 percent of people who undergo liver transplantation survive.
Maximizeliverfunction:
• The diet should be adequate calories and protein (75- 100 gm/day) unless
hepatic encephalopathyis present, in which case protein is limited.
• Restrictfluid and sodium if edema or fluid retention is present.
• Diuretic, thiazide – potassium supplement.
• The B vitamins and fat soluble vitamins (A, D, E, K).
• Adequate rest is needed to maximize regenerationofliver cells.
• Corticosteroidsdrugs to improve liver function in post necrotic cirrhosis.
Treat underlyingcause:
 if cirrhosis is from heavy alcoholuse, the treatment is to completely stop
drinking alcohol.
 If cirrhosis is causedby hepatitis C, then the hepatitis C virus is treated
with medicine
Prevent Infection:
 by adequate rest, appropriate diet, avoidance ofhepatotoxic substances.
Beta-blockeror nitrate
• Forportal hypertension. Beta-blockers canlowerthe pressure in the
varices and reduce the risk of bleeding. Gastrointestinalbleeding requires
an immediate upper endoscopyto look for esophagealvarices.
Complications
 Portalhypertension:
• The nodules and scartissue can compress hepatic veins within the liver.
• This causes the blood pressure within the liver to be high, a condition known
as portal hypertension.

29. • Portalvenous pressure is more than 15mmHg or 20 cm of water.
• Is characterizedby ↑venous pressure in the portal circulation,
spleenomegaly, large collateralvein, ascites, systemic hypertension, and
esophagealvarices.
• The common area to form collateralchannels are in the loweresophagus(
the anastomosisof the left gastric vein and azygos vein), the parietal
peritoneum, rectum.
• High pressures within blood vessels ofthe liver occurin 60% of people who
have cirrhosis
 EsophagealVarices:
• EsophagealVarices are a complex of tortuous veins at the lowerend of the
esophagealenlargedand swollenas a result of portal hypertension.
• 10-30%of UGI bleeding due to rupture of varices.
• 80% bleeding due to esophagealVarices.
• 20% due to gastric varices.
 Peripheral edema and Ascites:
• Edema results from decreasedcolloidaloncotic pressure from impaired
liver synthesis of albumin (hypoalbuminia)
• Ascites is the accumulation of serous fluid in the peritonealcavity.
• Protein move from the blood vessels via the largerpore of sinusoids into the
lymph space.
• When the lymphatic systemis unable to carry off the excess protein and
water, they leak through the liver capsule into the peritoneal cavity.
 Hepatic encephalopathy:
• Hepatic encephalopathyis a neuropsychiatric manifestationof liver damage.
• It can occurin any condition in which liver damage causes ammonia to
enter the systemic circulation without liver detoxification.
• Liver is unable to convert ammonia to urea. The ammonia crossesthe blood
brain barrier and produces neurologic toxic manifestations
• Clinical manifestations include changes in neurologicaland mental
responsiveness, ranging from sleepdisturbances to lethargy to deep coma.
• Grading systems are: early stage (stage0 and 1) euphoria, depression,

30. apathy, irritability, memory loss, confusion, drowsiness, insomnia.
• Lactulose , low-protein diet improves symptoms in 75 percent of cases.
• Later stages(stage2 and 3) include slow and slurred speech, impaired
judgment, hiccup slow and deep respiration, babinski reflex, stage 4 include
disorientation to time , place, person.
 Hepatorenalsyndrome:
• Hepatorenalsyndrome is a serious complicationof cirrhosis characterized
by functional renal failure with advancing azotemia, oliguria, and ascites.
MEDIAL MANAGEMENT IN PATIENT
 Fluid restriction < 1000 ml /Day
 Low salt diet
 Egg white BD
 Monitor Daily Weight and abdominal girth
 Advice for Completely stop of alcohol
 Inj. Vitamin K 1 amp I/V OD x 3 Days
 Arrange and transfuse 2 pint of FFP
 Arrange and transfuse 1 pint whole blood.
 Inj. Optineurone 1 amp to be added in 5% dextrose
Others Supportive Managements
 Inj .Taxim 1 gram TDS x 5 days
 Tab Lasilactone 1 tab Po OD x 5 days
 Tab Pantium 40 mg Po OD x 5days
 Tab Tone 100 PO BD x 5 days
 Tab Usoliv 300mg PO BD x 5days
 Inj. Optineurone 1 amp to be added in 5% dextrose x 3 days
Nursing management :
Assessment
 Assess the client client closelyfor the presence of early manifestations
such as :
 Hepatomegaly
 Carefully check the laboratory data.

31.  As the disease progresses , assessthe manifestations of
complications of cirrhosis such as ascites, portalhypertension
or hepatic encephalopathy
 History taking: pastand present health history (alcoholintake, medication,
infection etc) chief complain sign and symptoms of disease
 Physicalexamination
 Psychosocialassessment
Nursing Diagnosis
• Ineffective tissue perfusion related to bleedingtendenciesand varicesthat may
hemorrhage
Goal
• Hemorrhage will be prevented as evidenced by absence ofbleeding, normal
vital sign and urine output of at least0.5 ml/kg/hour
Interventions :
• Assess patient’s condition
• Monitor for hemorrhage bleeding from gums, melena, hematuria,
hematemasis.
• Assess vitalsign for sign of shock
• Monitor urine output
• Protectpatient from physical trauma to prevent hemorrhage
• Avoid unnecessaryinjection and apply gentle pressure after injection.
• Instruct the client to avoid vigorous nose blowing, straining with bowel
movement.
• Provide stoolsoftenerto prevent straining with rupture of varices.
• Advice to use soft tooth brush to prevent gum bleeding.
Activityintolerancerelated to bed rest, fatigue, lack of energy, and altered
respiratory function secondary to ascites.
Outcomes
The patient will maintain a balance betweenrest and activity as evidenced

32. by the absence offatigue
Interventions:
• Assess levelof activity tolerance and degree offatigue, lethargy, and malaise
when performing routine ADLs.
• Assistwith activities and hygiene when fatigued.
• Encourage restwhen fatigued or when abdominal pain or discomfort
occurs.
• Assistwith selectionand pacing of desired activities and exercise.
• Provide diet high in carbohydrates with protein intake consistentwith liver
function.
• Administer supplemental vitamins (A, B complex, C, and K).
Impaired skinintegrityrelated to pruritusfrom jaundiceand edema
Goal:‘Decreasepotentialfor pressure ulcer development; breaks in skin
integrity’
Interventions:
• Assess degreeofdiscomfort related to pruritus and edema.
• Note and recorddegree of jaundice and extent of edema.
• Keep patient’s fingernails short and smooth.
• Provide frequent skin care;avoid use of soaps and alcohol-basedlotions.
• Massageevery2 hours with emollients;turn every 2 hours
• Initiate use of alternating-pressure mattress or low air loss bed.
• Recommendavoiding use of harsh detergents.
• Assess skinintegrity every 4–8 hours. Instruct patient and family in this
activity.
• Restrictsodium as prescribed.
• Perform range of motion exercises every4 hours; elevate edematous
extremities wheneverpossible.
Highrisk for injury related to altered clotting mechanismsand altered level of
consciousness

33. Intervention
• Assess levelof consciousness and cognitive level.
• Provide safe environment (pad side rails, remove obstacles in room, prevent
falls).
• Provide frequent surveillance to orient patient and avoid use of restraints.
• Replace sharpobjects (razors) with saferterms.
• Observe eachstoolfor color, consistency, and amount.
• Be alert for symptoms of anxiety, epigastric fullness, weakness, and
restlessness.
• Testeachstooland emesis for occult blood.
• Observe for hemorrhagic manifestations:ecchymosis, epistaxis petechiae,
and bleeding gums.
• Recordvital signs at frequent intervals, depending on patient acuity (every
1–4 hours).
• Keep patient quiet and limit activity.
Disturbed body imagerelated to changesin appearance, and role function.
Goal:‘Patient verbalizes feelings consistentwith improvement of body image and
self-esteem’
Intervention:
• Assess changesin appearance and the meaning these changes have for
patient and family.
• Encourage patientto verbalize reactions and feelings about these changes.
• Assess patient’s and family’s previous coping strategies.
• Assistpatient in identifying short-term goals.
• Encourage andassistpatient in decisionmaking about care.
• Identify with patient resources to provide additional support (counselor,
spiritual advisor).
• Assistpatient in identifying previous practices that may have been harmful
to self (alcoholand drug abuse).
Fluid volumeexcess related to ascites and edema formation
Goal:Restorationof normal fluid volume

34. Intervention:
• Restrictsodium and fluid intake if prescribed.
• Administer diuretics, potassium, and protein supplements as prescribed.
• Recordintake and output every 1 to 8 hours depending on response to
intervention and on patient acuity.
• Measure and recordabdominal girth and weight daily.
• Explain rationale for sodium and fluid restriction.
• Prepare patient and assistwith paracentesis
Risk for imbalanced bodytemperature:hyperthermia related to inflammatory
process of cirrhosis or hepatitis
Goal:Maintenance of normal body temperature, free from infection
• Recordtemperature regularly (every4 hours).
• Encourage fluid intake.
• Apply coolsponges or icebag for elevated temperature.
• Administer antibiotics as prescribed.
• Avoid exposure to infections.
• Keep patient at rest while temperature is elevated.
• Assess forabdominal pain, tenderness
Ineffective breathing pattern related to ascites andrestriction of thoracic
excursionsecondary to ascites, abdominaldistention, and fluid in the thoracic
cavity.
Goal:Improved respiratory status
Intervention
 Elevate head of bed to at least30 degrees
 Conserve patient’s strength by providing rest periods and assisting with
activities.
 Change position every 2 hours.
Assistwith paracentesis orthoracentesis.

35.  Explain procedure and its purpose to patient.
 Have patient void before paracentesis.
 Support and maintain position during procedure.
 Recordboth the amount and the characterof fluid aspirated.
 Observe for evidence of coughing, increasing dyspnea, or pulse rate.
Application of Nursing Theory
Virginia Henderson’s independence theory
 Henderson defined nursing as , “ the unique function of the nurse is to
assistthe individual, sick or well , in the performance of those activities
contributing to health or its recovery( or to peacefuldeath ) that he would
perform unaided if he had the necessarystrength, will or knowledge. And to
do this in such a way as to help him gain independence of such assistanceas
soonas possible.
The 14 Basic components of Nursing Care
1. Breathe normally.
2. Eatand drink adequately.
3. Eliminate body wastes.
4. Move and maintain desirable postures.
5. Sleepand rest.
6. Selectsuitable clothes-dress andundress.
7. Maintain body temperature within normal range by adjusting clothing and
modifying environment
8. Keep the body cleanand well groomedand protect the integument
9. Avoid dangers in the environment and avoid injuring others.
10. Communicate with others in expressing emotions, needs, fears, or opinions.
11.Worship according to one’s faith.
12.Work in such a waythat there is a sense ofaccomplishment.
13.Play or participate in various forms of recreation.
14.Learn, discover, or satisfy the curiosity that leads to normal development
and health and use the available health facilities.

36. ASSESSMENT OF PATIENT ON THE BASIS OF 14 BASIS COMPONENTS
1 Breathe normally.
 Patient has difficulty in breathing especiallyin supine position due to ascites
2 Eatand drink adequately.
 Patient is taking so limited food
 She has loss of appetite
 She has restricted fluid intake
3 Eliminate body wastes.
 Patient has no problem related to bladder and bowel empty but her serum
creatinine levelis high (2.0 gm/dl)
4 Sleep and rest
 Patient has disturb sleep
 She has discomfort due to ascites
5 Selectsuitable clothes-dress andundress.
 Patient has no significantproblems in this area.
6 Maintain body temperature within normal range by adjusting clothing
and modifying environment
 Patient has sometimes mild fever
7 Keep the body cleanand well groomedand protectthe integument
 Patient looks dirty
 She has risk for skin breakdowndue to edema
8 Move and maintain desirable postures.
 Patient has only imitated mobility
9. Avoid dangers in the environment and avoid injuring others.

37. patient has no significant problems in these areas as the environment is safe
for patient
10. Communicate with others in expressing emotions, needs, fears, or
opinions.
 Patient is communicating limited to health team members because she has
some language problem
11. Worship according to one’s faith.
Patient has some problem in this areas becauseshe has no appropriate
environment for worship according to ownfaith.
12. Work in such a waythat there is a sense ofaccomplishment.
Patient has only limited involvement in activities of daily living
13. Play or participate in various forms of recreation.
 she does not seems to interested in recreationalactivities like talking to
other patients , and staffs
14. Learn, discover, or satisfythe curiosity that leads to normal
development and health and use the available health facilities
 She is not interested to learn .She is not curious towards environment
NURSING CARE PLAN
NURSING DIAGNOSIS
 Activityintolerancerelated to bed rest, fatigue, lack of energy, and altered
respiratory function secondary to ascites.
GOAL
 The patient will maintain a balance betweenrest and activity as evidenced
by the absence offatigue
PLANNING

38.  Assess levelof activity tolerance and degree offatigue, lethargy, and malaise
when performing routine ADLs.
 Assistwith activities and hygiene when fatigued.
 Encourage restwhen fatigued or when abdominal pain or discomfort
occurs.
 Provide diet high in carbohydrates with protein intake consistentwith liver
function.
 Administer supplemental vitamins (A, B complex, C, and K).
INTERVENTION
 Assessed levelof activity tolerance and degree of fatigue, lethargy, and
malaise when performing routine ADLs.
 Assistedwith activities and hygiene when fatigued.
 Encouragedrestwhen fatigued or when abdominal pain or discomfort
occurs.
 Encouragedto take diet high in carbohydrates.
 Encouragedto take egg white BD
 Administered supplemental vitamins B complex, (inj. neurobion in 5%
dextrose)as prescribed
 Administered vit. K as prescribed
Evaluation:
My goal was partially met as patient was complained of less fatigue than before.
NURSING DIAGNOSIS
 Fluid volumeexcess related to ascites and edema formation
Goal
 Restorationofnormal fluid volume
PLANNING
 Restrictsodium and fluid intake if prescribed.
 Administer diuretics, potassium, and protein supplements as prescribed.
 Recordintake and output every 1 to 8 hours depending on response to

39. intervention and on patient acuity.
 Measure and recordabdominal girth and weight daily.
 Prepare patient and assistwith paracentesisif needed.
INTERVENTION
 Restricted sodium as prescribed
 Restrictedfluid intake up to 1000ml/dayas prescribed.
 Administered diuretics (tab lasilactone 1 tab OD) as prescribed.
 Recorded intake and output strictly.
 Measuredand recorded abdominal girth and weight daily.
EVALUATION
 My goalwas not fulfilled as patient’s edema and ascites was increasedthan
before
NURSING DIAGNOSIS
 Ineffective breathing pattern related to ascites andrestriction of thoracic
excursionsecondaryto ascites
GOAL
Improved respiratory status
PLANNING
 Elevate head of bed to at least30 degrees
 Conserve patient’s strength by providing rest periods and assisting with
activities.
 Change position every 2 hours.
 Administer oxygen as needed
INTERVENTIONS
 Elevatedhead of bed (semi fowler’s position)
 Conservedpatient’s strength by providing restperiods and assisting with
activities.

40.  Changedposition every 2 hours.
 Encouragedfor deep breathing and coughing exercise
Evaluation
My goalwas partially met, as patient reported the improved breathing comfort
than before
NURSING DIAGNOSIS
 Risk for impaired skin integrityrelated to pruritusfrom jaundiceand edema
GOAL
Decrease potentialfor pressure ulcer development; breaks in skin integrity
INTERVENTION
 Assessedthe degree of discomfortrelated to pruritus and edema.
 Kept the patient’s fingernails short and smooth.
 Provided frequent skin care by changing the daily clothes and encouraged
to apply powder especially in-between the fingers and toes.
 Changedthe patient’s position in every 2 hours
 Assessed skinintegrity in every 4–8 hours. Instruct patient and family in
this activity.
 Restrictedsodium as prescribed.
 Encouragedto Perform range of motion exercises every4 hours;
 Elevatededematous extremities.
EVALUATION
My goalwas fully met, as patient did not developed pressure sore and any other
skin lesionduring hospitalization
NURSING DIAGNOSIS
 Highrisk for injury / bleedingrelated to altered clotting mechanisms.
GOAL
Bleeding tendency will be minimized

41. PLANNING
 Observe for hemorrhagic manifestations:suchas ecchymosis, epistaxis
,petechiae, andbleeding gums.
 Observe eachstoolfor color, consistency, and amount.
 Be alert for symptoms of anxiety, epigastric fullness, weakness, and
restlessness.
 Testeachstooland emesis for occult blood.
 Recordvital signs at frequent intervals, depending on patient acuity (every
1–4 hours).
 Administer vit K as prescribed
 Transfuse fresh frozen plasma as prescribed.
INTERVENTION
 Observedfor hemorrhagic manifestations:such as ecchymosis, epistaxis
,petechiae, andbleeding gums.
 Observedeachstoolfor color, consistency, andamount.
 Closelyobservedthe symptoms of internal hemorrhage such as anxiety,
epigastric fullness, weakness,and restlessness.
 Recordedvital signs at frequent intervals,
 Administered vit K as prescribed
 Transfusedfresh frozen plasma as prescribed.
EVALUATION
 My goalwas fully met as the patient did not developed the signof
haemorrhage during hospitalization.

42. DAILY PROGRESS NOTEOF PATIENT
Date :- 2068/07/13
Admission day
 A patient was admitted in male medical ward fromOPD with history of
abdominal distention , bilateral pedal edema , mild shortness of breathing and
loss of appetite .
 On admission patient’s vitals sign were:
B.P=110/60 mmof hg, R.R=22/min,
Pulse=98/min, Temp.=98ºf weight: 37kg
 Patient’s general condition was ill looking.
 Mild to moderate shortness of breathing was noticed.
 USG abdomen and all base line investigation was ordered
MAJOR NURSING INTERVENTION
 Admission procedurecarried out
 Vein open done and stat medication given
 All the ordered investigation send
 Monitored vital sing
 Maintained intake and output chart
 Frequently assessed the patient’s condition
 Monitored Weight
1nd
day of admission( 2068/07/14)
 Patient’s general condition was not improved than yesterday.
 Injection vit k added
 Doseof tablet lasilactone changed from½ tab to one tab
 Fluid restriction <1000ml/day
 Low salt diet and egg white BD ordered
 Arrangeand transfuse1 pint of FFP
B.P=100/60 mmof hg, R.R=22/min,
Pulse=96/min, Temp.=98ºf weight: 37kg abdominal girth =31”
Intake=1050ml output= 1000ml

43. MAJOR NURSING INTERVENTION
 Assessed in all morning care
 Monitored of vital sign regularly
 Attended doctor’s round.
 Hair comb done
 Nail care given
 I/V site changed
 Daily weight and abdominal girth taken and recorded .
 Detail history was done.
2nd
day of admission( 2068/07/15)
 Patient’s general condition was as same as yesterday.
 Serumcreatinine and platelet test order for tomorrow.
 Fluid restriction <1000ml/day
 Low salt diet and egg white BD ordered
 Arrangeand transfuse1 fresh wholeblood.
B.P=120/70 mmof hg, R.R=20/min,
Pulse=96/min, Temp.=98.8ºf weight: 37.5kg abdominal girth =32”
Intake=1050ml output= 9050ml
MAJOR NURSING INTERVENTION
 Assessed in all morning care
 Monitored of vital sign regularly
 Attended doctor’s round.
 Hair comb done
 Daily weight and abdominal girth taken and recorded .
 Encouraged for intake of food
 Head to toe physicalexamination was done.
3nd
day of admission( 2068/07/16)
 Patient’s general condition was worsethan yesterday.

44.  Complain of shortness of breathing and abdominal discomfort.
 Serum creatinine and platelet test was send and reportcollected (creatinine
=1.7mg/dl, platelet 67,000 mm3)
 1pint fresh whole blood was transfused.
B.P=140/90 mmof hg, R.R=22/min,
Pulse=96/min, Temp.=97ºf weight: 37.5kg abdominal girth =33.2”
Intake=800ml output= 700ml Sp02 =92% without o2.
MAJOR NURSING INTERVENTION
 Assessed in all morning care
 Monitored of vital sign regularly
 Attended doctor’s round.
 Hair comb done
 Daily weight and abdominal girth taken and recorded .
 Encouraged for intake of food
 High fowlers’ position was maintained
4nd
day of admission( 2068/07/16)
 Patient’s general condition was worsethan yesterday.
 Complain of shortness of breathing and abdominal discomfort more severe
than yesterday.
 Patient was drowsy and lethargic
 Nothing was taken fromyesterday evening
 Patient party asked for discharge
 Patient was discharged on request.
B.P=130/90 mmof hg, R.R=22/min,
Pulse=100/min, Temp.=99ºf weight: 38kg abdominal girth = 34”
Intake=600ml output= 500ml Sp02 =90% without o2.
MAJOR NURSING INTERVENTIONS
 Assessed in all morning care
 Attended doctor round .
 Removed the i/v cannula
 Performed all dischargeprocedure
Provided dischargeteaching on the following topics:

45.  Medication
 Diet
 Follow up
 Rest and sleep
 Regular check up
 Prevention of recurrenceof diseaseetc.
SPECIAL GAGETS USED IN MY PATIENT
 Sphygmomanometer
 Stethoscope
 ECG monitoring
 U.S G machine.
 Knee hammer.
 Thermometer
 Pulse oxymeter.
Discharge medication
 Tab Lasilactone 1 tab Po OD x 7 days
 Tab Pantium 40 mg Po OD x 10 days
 Tab Tone 100 PO BD x 7 days
 Tab Usoliv 300mg PO BD x 7 days
 Inj. Vitamin K 1 amp I/V OD x 3 Days
 Fluid restriction < 1000 ml /Day
 Low salt diet
 Egg white BD
Follow up after 1 week and sos.
Learned from the Experience
◦ Identified the complete health need of old age .
◦ Provide comprehensive nursing care to the patient having cirrhosis of
liver
◦ Provide the opportunity for in-depth study of disease condition
◦ Developcompetencyin handling such disease condition

46. ◦ Provide the opportunity to o apply the Nursing theory in real
situation.
◦ Identified the evaluate the educationalneed of the patient and
patient family.
SIGNIFICANCE FINDINGSAND SUMMARY
chief complain on Admission (2068/07/13)
 Abdominal distention since 15-16 days
 Bilateralpedal swelling since 10-12 days
 Moderate shortness of breathing since 5-7 days
 Loss of appetite since 15-16 days
On Physicalexaminations
Abdominal distention +
Fluid thrill +
Swelling of face +
Hepatomegaly+
Icterus +
SignificantInvestigations
 SGOT/AST : 187.0 U/L
 AGPT/ALT: 88.0 U/L(˂40.0 U/L)
 Albumin : 3.4 gm/dl (3.5-5.5 gm/dl)
 Bilirubin Total: 2.2mg/dl (0.4-1.0 md/dl)
 Prothombin time: 23.3 sec(14-16 sec)
 INR : 1.8 ( o.8-1.2)
 Creatinine : 2.0 mg /dl
 Haemoglobin: 7.8 gm/dl
 WBC : 11,600Mm3
 Platelets : 61,000Mm3

47. Liver ultrasound
 impression: s/o cirrhosis of Liver, Moderate Ascites
MedicalManagement
 : fluid restriction
 Transfusionof 2 pint FFP
 Vit K and inj. polybion supplementary
 diuretic drugs (lasilaction)
 Daily weight and abdominal girth monitoring
Prognosis ofpatient
 initially improved than detoriation of condition
 Dischargedonrequest on 2068/07/17

48. PATHOPHYSIOLOGY OF CIRRHOSIS OF LIVER
Liver insult, Alcohol ingestion, viral hepatitis, exposure to toxin,
Hepatocyte damage
Liverinflammation
WBC,fever,anorexia,
Pain, , nausea,vomitingfatigue,
Alterationinbloodandlymphflow
Livernecrosis
Liverfibrosisand
scarring
Portal hypertension
Acites,Edema,spleenomegaly
Anaemia,thrombocytopenia,
leukopenia
Varices
Esophageal varices,superficial
abdominal vertices(caputmedusa)
Hemorrhoids
 Decreasedbilirubin
metabolism/biliarytree
damage/obstruction
 Hyperbilirubinemia
 Jaundice
 Decreasedbile in
gastrointestinal tract
 Lightcoloredstool
 Increasedurobilinogen
 Dark urine
 Decreasedvit.K
absorption
 Bleedingtendency
Hormone metabolism
Androgen&estrogen
 Gynaecomastia
 Loss of body
hair
 Menstrual
dysfunction
 Spiderangioma
 Palmar
erythemia
ADH & Aldestrone
 Edema
 Metabolismof protein
 Decreased Plasmaprotein
 Ascites,edema
 Carbohydrate &Fat metabolism
 Hypoglycemia
 Malnutrition
Liverfailure
Inabilitytometabolize ammoniatourea
Hepaticencephalopathy
Hepaticcoma
Death
Increasedserumammonia,alterationin
sleep,asterixis,respiratoryacidosis,foul
breath