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NRSG353 Nursing Care Plan in Liver Cirrhosis: Assessment Task 1

NRSG353 Assessment Task 1 –Case Study

Weighting: 40% 

Word count: 1600 words (every question has a specific word count, which must be adhered to) 

Instructions: 

• Students are to choose one (1) of the case studies below and answer the associated questions. The assignment is to be presented in a question/answer format not as an essay (i.e. no introduction or conclusion). • Each answer has a word limit (1600 in total); each answer must be supported with citations. • A Reference List must be provided at the end of theassignment. • Please refer to the marking guide available in the unit outline for further information. ** The following questions must be answered for your chosen case study ** 

The following questions relates to the patient within the first 24 hours: 

1. Outline the disease, causes, incidence and risk factors. Discuss the impact of the selected disease on the patient and their family (450 words) 

2. Discuss three (3) common signs and symptoms of the selected disease and explain the underlying pathophysiology of each (350 words) 

a. This can be done in the form of a table – each point needs to be appropriately referenced 

3. Discuss the pharmacodynamics & pharmacokinetics of one (1) common class of drug relevant to the chosen patient (300 words) 

a. This does not mean specific drugs but rather the class that these drugs belong to. 

4. In order of priority, develop a nursing care plan for your chosen patient who has just arrived on the ward from ED. Nursing care plan goals, interventions and rationales must relate to the first 8 hours post ward admission (500 words)

a. This can be done in the form of a table – each point needs to be appropriately referenced 

 Case Study 1 

Mrs Sharon McKenzie is a 77 year old female who has presented to the emergency department with increasing shortness of breath, swollen ankles, mild nausea and dizziness. She has a past history of MI at age 65. During your assessment Mrs McKenzie reports the shortness of breath has been ongoing for the last 7 days, and worsens when she does her gardening and goes for a walk with her husband. On examination her blood pressure was 170/110 mmHg, HR 54 bpm, respiratory rate of 30 bpm with inspiratory crackles at both lung bases, and Sp02 at 92% on RA. Her fingers are cool to touch with a capillary refill of 1-2 seconds. Mrs McKenzie states that this is normal and she always has to wear bed socks as Mr McKenzie complains about her cold feet. Her current medications include: digoxin 250mcg daily, frusemide 40mg BD, enalapril 5mg daily, warfarin 4mg daily but she sometimes forgets to take all of her medications. The following blood tests were ordered: a full blood count (FBC), urea electrolytes and creatinine (UEC), liver function tests (LFT), digoxin test, CK and Troponin. Her potassium level is 2.5mmol/L. Mrs McKenzie also has an ECG which showed sinus bradycardia, and a chest x-ray showing cardiac enlargement and lower-lobe infiltrates. Impression: Congestive cardiac failure

Case Study 2

Ms Maureen Smith is a 24 year old female who presented to her GP for ongoing gastrointestinal bleeding, abdominal pain and fatigue which has been worsening, and was referred to the local hospital for further investigation. Maureen was diagnosed with rheumatoid arthritis (RA) when she was 15 years old, and has experienced multiple exacerbations of RA which have required the use of high dose corticosteroids. She is currently taking 50mg of prednisolone daily, and has been taking this dose since her last exacerbation 2 months ago. Maureen also has type 2 diabetes which is managed with metformin. She is currently studying nursing at university and works part-time at the local pizza restaurant. On assessment, Maureen’s vital signs are: PR 88 bpm; RR 18 bpm; BP 154/106 mmHg; Temp 36.9ºC: SpO2 99% on room air. She has a body mass index (BMI) of 28kg/m2 and the fat is mainly distributed around her abdominal area, as well as a hump between her shoulders. Maureen’s husband notes that her face has become more round over the past few weeks. Her fasting BGL is 14.0mmol/L. Blood test results show low cortisol and ACTH levels, and high levels of low density lipoprotein cholesterol. She is awaiting a bone mineral density test this afternoon, and is currently collecting urine for a 24-hour cortisol level measurement. Impression: Exogenous Cushing’s syndrome

Case Study 3

Mr Nathan James is a 48 year old male who was admitted to the high dependency unit for investigation of jaundice and ascites. He is an interstate truck driver and is married with 2 children. Mr James is a current smoker and known to consume 2 of beer per day. He has a previous (15 years ago) history of recreational drug use and was diagnosed with Hepatitis C 10 years ago. On assessment: Mr James is lethargic but orientated to time, place and person and slightly irritable. He is slightly tachypnoeic with moderate use of accessory muscles. His wife reported that Mr James has been spitting blood stained sputum for the last few weeks with no associated cough or shortness of breath. Mr James reports that he has lost 9 kilos in weight which he attributed simply to a lack of appetite. No changes were reported with his urine output. On examination his sclera is mildly jaundiced and he has some “unexplained” bruises on his arms and legs. His abdomen is tight and distended and pitting oedema noted on his ankles. Observations: BP: 115/60mmHg, HR: 110 bpm, RR: 24 bpm, SpO2: 88% on RA, 95% on 6L via Hudson Mask, Temp: 37.8C Impression: Liver Cirrhosis

Case study of liver cirrhosis

Answer

Nursing care plan in Liver Cirrhosis

Outline the disease

Liver cirrhosis is a late stage of liver fibrosis caused by liver disease and conditions like hepatitis and consumption of excessive alcohol. It explains the damaging of the liver. In cirrhosis, the scar tissue formed in the liver which increases with the disease progression and altering the functional capabilities of the liver and results in life threatening situations.      

Causes of Cirrhosis 

The most common cause of the disease is viral infections of the liver along with fatty liver, obesity and diabetes and alcohol abuse. The other causes of disease development are (Schuppan & Afdhal, 2008):

  • Cystic fibrosis
  • Deficiency of Alpha-1 antitrypsin enzyme 
  • Autoimmune diseases like autoimmune hepatitis, primary sclerosing cholangitis, and primary biliary cholangitis.
  • Blockage in the bile duct. 
  • Exposure to environmental toxins, infections, and consumption of unethical drugs.    

In our case study, it has been identified that Mr. James has a previous case history of hepatitis C and drug abuse which increases the chances of cirrhosis. At present regular consumption of alcohol along with smoking is enhancing the risk factors for him.  


Risk factors 


The risk factors for the disease development identifies that excessive consumption of alcohol along with obesity is elevating the onset of disease. In obese, it has been recognised that non alcoholic fatty liver and non alcoholic steatohepatitis are a risk for the development of cirrhosis.  Furthermore, the development of chronic hepatitis is responsible for liver cirrhosis (Mayo Clinic, 2019).    


Incidence of Cirrhosis  


In 2010-12, liver disease was the 11th leading cause of premature death in Australia (AIHW, 2019). The rate of death due to liver disease was increased 48% over the past three decades (AIHW, 2019). The premature death rate duet o liver disease is high among the men. It was 69%. In addition, the Aboriginal people are vulnerable to liver disease particularly in hepatitis B (AIHW, 2019). The death rate in indigenous people due to liver disease is higher compared to non indigenous Australians. It was recognised that in 2008-12 the rate is 3 times higher in the case of male and 5 times higher in the case of the female indigenous population (AIHW, 2019). The main reasons behind the aggressive onset of the disease development are fatty liver, overweight, diabetes, hypertension, and hypercholesterolemia in society. In addition, excessive consumption of alcohol is also interfering with disease development. Therefore, restricted life style with dietary modification and proper medication can eliminate the chances of disease development.       

Impact on family


 Liver cirrhosis is a progressive disease which develops slowly over many years. The process of the disease allows the development of scar tissue in the liver to stop the function of the liver(Murrell, 2017). It is a process of long term liver damage in which healthy liver tissues are replaced by the scar tissues and the functioning capabilities of the liver are altered.  It can block the flow of blood through the liver and damage the tissue.     

The person suffering from the illness can develop various symptoms which can increase their irritability and restlessness along with fatigue and loss of appetite. The disease not only affects the individual as it has a great impact on their family. The family member needs to support the patient in their intervention process.


Signs and symptoms of Cirrhosis

 

Symptoms Pathophysiology
JaundiceHigh bilirubin level in blood is known as jaundice which is a common symptom of liver cirrhosis. Haemoglobin is breakdown into un-conjugated bilirubin and other substances in the blood. Therefore, albumin binds the un conjugated bilirubin and transport to the liver. In the liver, it is conjugated with glucuronic acid and excreted into the duodenum. Thus, in intestine bacteria metabolized the bilirubin and converted into urobilinogen which is eliminated with feces and reabsorbed by the hepatocytes. In liver cirrhosis, the functioning capabilities of the hepatocytes are decreased as a result the bilirubin reabsorbed process is inhibited (Herrine, 2018). In addition, lack of albumin in cirrhosis patients is also disturbing the transportation process of bilirubin. As a result, the blood bilirubin level is increased in cirrhosis patients which indicating the occurrence of jaundice.       
Ascities or oedema 
 The deposition of fluid in the abdomen is known as ascities and deposition of fluid in legs is called oedema. Both are common symptoms in liver cirrhosis. In cirrhosis, development of portal hypertension released the vasodilators which affect the splanchnic arteries and decrease the arterial blood flow and pressure.  in addition, progressive vasodilation can cause activation of vasoconstrictor and antinatriurectic mechanisms to normalised the perfusion pressure. As a result of the sodium and water retention of the body precipitate. It has been recognised that in the late stage of liver cirrhosis water deposition is more pronounced compared to sodium retention. Furthermore, the patient with ascities has urinary sodium retention, and dilutional hyponatremia along with elevated total body sodium. It is indicating the inability of the liver cells to produce enough blood protein albumins (Such, 2018).          

Bleeding 
In cirrhosis, portal hypertension can cause the blood to be redirected towards the small veins. Therefore, scan in liver tissue can block the blood flow through the liver as a result of blood flow through the veins and extra blood flow can increase the pressure.  The extra pressure can break the vein and cause serious bleeding. In addition, portal hypertension can cause enlarged veins in the esophagus or in the stomach which leads to life threatening bleeding in cirrhosis patients. The poor functioning capabilities of the liver are inhibiting the production of blood clotting factors which accelerate the continuous bleeding (Hilzenrat & Sherker, 2012)

  

Pharmacodynamics & Pharmacokinetics of Drug 


Furosemide pharmacokinetics 

It is a diuretic which can be used in anti-hypertensive therapy and for treating oedema. After oral consumption, 65% of the dose can be absorbed. It is a weak carboxylic acid exists in the separated form in the gastrointestinal tract. It is incompletely absorbed on oral administration but absorbs rapidly. The effects of the drugs can over within 4 hours of the administration. The prime absorption site of the drug is upper duodenum and the optimum pH is 5. The drug can bind to plasma protein up to 99% (Furosemide, 2019). It can bind albumin and exert its function. The drug can secrete efficiently by the transport of organic acid in the proximal tubule and bind the sites on sodium, potassium, chloride symporters in the ascending limbs. It has been recognise that 65% of furosemide is excreted in urine as unchanged compound and the rest can be conjugated with glucuronic acid in the kidney. The exceptional adverse effects can result due to fluid and electrolyte imbalance.

Furosemide Pharmacodynamic

Mechanism of action:

It is a diuretics and the main renal action of the drug is to restrict the active chloride transport in the ascending limb of the body along with reducing the sodium re-absorption from the nephron and creating isotonic or hypotonic urine (Medicines, 2019).   

The experimental studies indicating that furosemide acts on the entire nephron along with exception of distal exchange site of the kidney. The main affecting site is ascending limb of the Henley loop and the complex effects on the renal circulation. The drug can help in diverting the blood flow to the outer cortex from the juxta-medullary region.

The studies indicating that prostaglandin biosynthesis and rennin angiotesin system can get affected by the administration of furosemide and it can alter the renal permeability of the glomerulus to the serum protein.   In addition, administration of furosemide can cause accumulation of sodium and chloride along with the fluid in the body. Thus, careful administration is essential to avoid consequences. 

Nursing Care Plan 

 

DiagnosisPlanning Intervention Rationale 
The patient is suffering from fatigue, mood alteration, weakness, agitation. After 4 hours of nursing, intervention patient will able to achieve sufficient sleep. 
Evaluate the stress level.
Reduce fluid intake.
Provide suitable and supportive atmosphere.

The complication of the condition can make the patient restless and interfere with his sleeping patterns (NRSNG, 2018).
Reduce sensory stimulation of the environment can help the patient. 
The patient is suffering from mild jaundice with poor muscle tone and abdominal distension After 5 hours of nursing intervention, the patient appetite will be improved.  
During this period monitor the vital signs.
Consider the food preferences of the patient.
Administrate small and frequent meal without salt.
Motivate to take nutritious food.

It can stimulate the appetite of the patient. 

Ascities has a strong impact on the patient appetite in cirrhosis (Wiegand & Berg, 2013)

The physiological disturbance can impair the food intake and digestion process of the patient.  

Thus, conserving energy can reduce the metabolic demands and promote cellular regeneration in the liver cell(Wiegand & Berg, 2013).  
The patient has ascities, and  respiratory distress along with fatigueAfter 2 hours of nursing intervention, the patient will feel better and his complications will be partially released. 
Relaxing the patient by providing comfort and support.

Teach the relaxation techniques along with the breathing techniques. 
Provide respiratory support in case of a severe respiratory problem. 
Relaxation techniques and supportive environment can calm the patient and he can feel better. 

The noisy environment along with physical discomfort stimulates the irritation (Nusrat, 2014)
The patient has oedema, abdominal distension, jaundice and respiratory difficulties which  needs attentionAfter 6 hours of intervention, the patient will achieve stabilise fluid volume and decrease the incident of oedema 
Monitoring the vital signs and measure fluid input and output.
Continually monitoring BP.
Measure the respiratory status.
Restrict the consumption of fluid and sodium intake.  
Administration of diuretics.
Increase in BP indicating the elevation f fluid in the body.
Increase respiratory discomfort indicating further deposition of water in the body (Nusrat, 2014).
Sodium restriction can avoid fluid retention in extra vascular space. 
Fluid restriction can avoid the onset of dilutional hyponatremia. 

Administration of diuretics can remove the ascitis fluid. 
Physical discomfort of the patients along with anxiety and feeling of helplessness After 8 hours of nursing intervention, the patient condition will be stable and he would feel better. 
Start the verbal communication with the patient.
Encourage the patient by showing positive and supportive attitudes.
Encourage the family to interact with the patient. 
Verbal communication can help the patient to avoid the feelings of quit. In the case of James, control of alcohol consumption during the treatment is essential for his recovery (NRSNG, 2018).. 
Therefore, supportive behaviour of the staffs and his family member can motivate him to stop the habits and concentrate on the intervention process (NRSNG, 2018).

The non judgemental and emotional behaviour of the nursing staff can ensure free access to patient participation in the intervention process. 


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