S.S.

AGRAWAL COLLEGE OF NURSING

TRAINING COLLEGE AND RESEARCH
CENTER,NAVSARI.

SUB - MEDICAL SURGICAL NURSING

TOPIC – Medical Care plan on cirrhosis of liver

SUBMITTED TO, SUBMITTED BY,

MRS.NIKITA PATEL MS AVNI PATEL
ASSISTANT PROFESSOR 1st YEAR M.SC (N)
SSAGCON,NAVSARI SSAGCON,NAVSARI

DATE OF SUBMISSION
9-7-21
OUTLINE
 Introduction
 History collection
 Physical examination
 Investigation
 Pharmacological management
 Theory application
 Nursing process
 Diet
 complication
 Health education
 Home remedies
 Summary
 Conclusion
 Bibliography
INTRODUCTION

Name- Patel Avni c.

Class- First year M.sc Nursing

Topic- Medical care plan on cirrhosis of liver

Date-9-7-21

Introduction

As a part of our clinical experience in medical surgical nursing,we posted in

yasfeen hospital for training.I selected one patient for my care plan
requirement.

( Cirrhosis of liver)
 HISTORY COLLECTION

INFORMATION DATA
Name- Mr. Sureshbhai k. Halpati
Age- 60 year
Sex- Male
Address- shivaji chowk,Navsari
Education- 4th pass
Religion- hindu
Occupation- labour work
Bed number-5
Ward- Male Medical ward
Medical diagnosis- cirrhosis of liver
Surgery- not performed
Date and time of admission-

CHIEF COMPLAINT
 Abdominal distension 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
 Fatigue
HISTORY OF PRESENT MEDICAL ILLNESS
Mr.Sureshbhai having present complaints are:
 Swelling of lower legs
 Moderate shortness of breathing
 Fever
 Weakness
 Loss of appetite
 Fatigue
HISTORY OF PRESENT SURGICAL ILLNESS
No any significant data about present surgical illness.

HISTORY OF PAST MEDICAL ILLNESS

No any significant data about past medical illness like jaundice,dengue,malaria etc.
Trauma and accidents-no any history of trauma and external injuries and accidents.
Hospitalization ,operations or special treatment- He had no history of previous
hospitalization,but he treated in opd with same problem before 4 month.
Allergies- according to my patient she has not known allergies to any food,drugs and others.

HISTORY OF PAST SURGICAL ILLNESS

No any significant data about past surgical illness history.

FAMILY HISTORY

KEY
Sureshbhai (60 Year) Meenaben(55 year)

Male

Harsh(30 year)
Female

patient
FAMILY COMPOSITION

Name of Ag sex Educatio occupatio Incom Relationshipwit Healt

the e n n e h pt h
family status
member
1.Sureshbha 60yr male 4th pass labour 10000 patient ill
i
2.Meenaben 55yr femal illterate housewife - wife healthy
e
3.Harsh 30 yr male B.com clerk 1,20,ooo son healthy

FAMILY HISTORY
Mr. Sureshbhai living in a nuclear family.No any hereditary disorder present in their
family.All the members are well cooperate with each other.

PERSONAL HISTORY
Mr Sureshbhai is looking poorly nourished,skin colour is yellow,he has a bad habit of
alcoholism.he is a non vegetarian .
Personal hygiene:
Oral hygiene-once a time
Bath- once in a day daily.
Sleep and rest- 7 hours/day
Elimination:
Bowel per day : regular
Urine frequency: 1600ml/day
Mobility and exercise:
He is not doing exercise.
Environmental History:
Type of house-pakka
Ventilation-good
Water supply-municipality
Electricity-good
Drainage-closed drainage
Cooking-separate kitchen
Location of house-In city
Pet animals-No

PHYSICAL EXAMINATION

GENERAL HEALTH:
 Nourishment-poorly nourished
 Body built-normally built
 Health-ill
 Activity-dull
 Facial expression-dull
 Level of consciousness-conscious
Height-4 feet 6 inch
Weight-60kg
Temperature-99 degree c
Pulse-86 beats/min
Respiration-18 breath/min
Blood pressure-120/80mm/Hg

HEAD AND FACE:

  Hair-Black
 Scalp-dandruff present,no injury,
 Skull-normal in shape
 Face – slight edema
 Sinuses-no swelling,tenerness
EYES:
 Eye brow-symmetrical
 Eyelashes-no any infection
 Eye lid-no edema
 Eye ball-euqally reaction to the light
 Conunctiva-pale
 Sclera-yellowish
 Lens-opaque
 Vision-normal
EAR:
 External ear- no discharge
 Tympanic membrane-normal
 Hearing acuity-normal
 Drainage from ear-no discharge ,pus
 Hearing aid-not used
NOSE:
 Location- centrally located
 Nasal deviation-not found
 Bleeding-no
 Patency of the nostrils-patented
 Condition of nasal mucosa-pale in colour
 Flaring nostrils-not presented
 Inflammation-not found
 Nasal polyps-not found
MOUTH:
 Lips-dry
 Oral cavity-pale mucous membrane of oral cavity
 Teeth-normal
 Tounge-slightly dry and coated tounge
 Vocal cord,uvula and tonsils-not enlarged and inflammed
 Speech disorder-not presented
NECK:
 Movement-full and smooth range of movement
 Jugular vein-not enlarged
  Condition of thyroid-no enlargement of thyroid gland
CHEST:
 Respiratory rate-18 breath/min
 Depth of respiration –normal depth
 Quality of respiration- dyspnoea in lying position
CHEST INSPECTION:
- Lateral diameter is wider than anterior posterior diameter
- Sternum is located at the midline
- Even expansion of the chest during breathing
- No intercostals retraction
CHEST PALPATION:
- No tenderness,lump or depression along the ribs.
Percussion
- Deep resonant sound heard all over the lungs.
Auscultation
- Breath sounds are heard in all areas of the lungs
- Inspiration longer than expiration
- No rhonchi,wheezing sounds was presented

HEART
 Pulse rate-74 beats/min
 Character of pulse-normal
 Blood pressure-110/80mm/hg
 Varicosities-absent
 Visible external jugular veins-absent
 Systolic or diastolic murmur-absent

ABDOMEN
 Size and shape of abdomen-distended abdomen
 Inspection-no lesion
 Palpation-moderately enlarged liver,tenderness in right hypocardium
 Shifting dullness-present
 Distended abdominal veins-slightly
 Fluid thrill-present
 Abdominal girth-33 inch
 Bowel sound-present
GENITAL AREA
 Lesion or tumors of rectal area-not found
 Abnormalities of genito urinary area-not found

EXTREMITIES
 Motor strength and mobility-slightly reduced
 Enlargement and stiffness of joint-not present
 Range of motion-active

COMFORT,SLEEP AND REST

 Location of pain-right hypochondrium ,tenderness

INVESTIGATION

 Liver function- serum albumin and prothrombin time are the best indicators
of liver function.the outlook is poor with an albumin level below 28g/l.the
prothrombin time is prolonged commensurate with the severity of the
liverdisease.

 Liver biochemistry-slightly elevation in the serum ALP,aminotransferases.in

decompensated cirrhosis of all biochemistry is deranged.

 Serumelectrolytes-a low sodium indicates severe liver disease due to a defect

in free water clearance or to excess diuretic therapy.

 Serum creatinine-An elevated concentration>130 mol/l is a marker of worse

prognosis.

 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 surafce and
distortion of the arterial vascular architecture.the patency of the portal and
 hepatic vein can be evaluated.It is useful in detecting hepatocellular
carcinoma.

 CT scan-arterial phase contrast enhanced scans are useful in the detection of

hepatocellular.

 Endoscopy- is performed for the detection and treatment of varices and portal
hypertensive gastropathy.

 MRI scan- MR angiography can demonstrate the vascular anatomy and MR

cholangiography the biliary tree.

IN CLIENT
Liver function test
SGOT 187u/l
SGPT 88u/l
Alkaline phosphate 124u/l
Total protein 6.4gm/dl
albumin 3,4gm/dl
Prothrombin time 23.3 sec
INR 1.8
Bilirubin 2.2 mg/dl
creatinine 2.omg/dl
haemoglobin 7.8gm/dl
WBC 11,600mm3
platelets 61,000mm3
USG Findings cirrhosis of
liver

CBC PROFILE
Parameter Client value Normal value Remark
hb 7.8 g/dl 13-15mg/dl Decrease
Wbc 11,600mm3 4000-1100mm3 Increase
Platelet 61000mm3 1,50,000-4,00,000 Decrease
Prothrombin time 23.3 sec 14-16 sec Increase
INR 1.8
Neutrophil 90% 40-70% Increase
Lymphocyte 10% 30-35% Decrease
Esinophil 00 1-2% Normal
basophil 00 0-1% normal
 BIOCHEMISTRY
REPORT

Blood sugar 129 mg/dl 60-180mg/dl Normal

Creatinine 2mg/dl 0.4-1.4mg/dl Increase
Sodium 142.7mmol/l 135-150mmol/l Normal
Potassium 3.45mmol/l 3.3-5.5mmol/l Normal
Total protein 6.4gm/dl 6-8gm/dl Normal
albumin 3.4gm/dl 3.5-5.5mmo/l Decrease
Alkaline phosphate 124.0 64-306 Normal
Bilirubin total 2.2mg/dl 0.4-1.o Increase

ECG- Normal sinus rhythm,non specific t wave abnormality.

URINE REPORT-
 Colour-light yellow
 Reaction-acidic
 Albumin-nil
 Sugar-nil
 Transperancy-clear
 Pus cell-2-4HPF
 Epithelial cells-3-4/HPF

PHARMACOLOGICAL MANAGEMENT

Sr no Drug Dose Route Action

1 Inj.taxim 1gm IV antibiotic

2 Tab lasilactone 50 mg Oral Aldeosterone
antagonist
3 Tab pantium 40mg Oral Proton pump
inhibitor
4 Tab tone 100mg Oral Vitamin b1
5 Tab usoliv 300mg Oral Cholingocytes
6 Inj.optineurone 1 amp IV multivitamin
Drug name Dose,route Mechanism of Indication contraindication Side effect Nursing
action responsibilities
Inj.taxim 1gm Taxim Injection Urinary -enteric fever Severe diarrhoea. -asess the
works by tract -severe Nausea. patient
Route inhibiting the infection infection Vomiting. condition.
IV formation and -Lung - Stomach pain. - monior the
growth of infection hypersensitivity Itching or skin hemodynamic
bacterial cell - throat rash. status
wall which infection Headache. -assess for
eventually leads -gallbladder Dizziness. allergic
to the death of infection Fits. reaction
the bacteria - bile duct -maintai IO
responsible for infection chart.
causing -maintain
infection. rights of
patients.
Drug name Dose,route Mechanism Indication contraindicatio Side effect Nursing
of action n responsibilitie
s
Inj 1 amp Pyridoxine, Vitamin allergy  Headache -asess the
optineuron A Vitamin b12 and  Nausea patient
e Route B6 nutritional  Vomiting condition.
Supplement deficiencie  Indigestio - monior the
IV Is Required s n hemodynamic
For The  Flatulence status
Proper (gas) -assess for
Function Of  Diarrhoea allergic
Glucose,  Dizziness reaction
Fats, And  Fatigue -maintai IO
Proteins In  Sleepiness chart.
The Body. It -maintain
Is Also rights of
Required For patients.
The Growth - check the
And dosage of the
Developmen drug.
t Of The
Brain,
Nerves,
Skin, And
Many Other
Parts Of The
Body.
THEORY APPLICATION

 VIRGINIA HENDERSONS INDEPENDENCE THEORY

Henders defined nursing as ,” the unique function of the nurse is to assist the
individual ,sick or well,in the performance of those activities contributing to health or its
recovery that he would perform unaided if he had the necessary strength will or
knowledge.and to do this in such a way as to help him gain independence of such assistance
as soon as possible.

The 14 basic components of nursing care

1. Breathe normally.
2.Eat and drink adequately.
3.Eliminate body waste.
4.Move and maintain desirable postures,
5.sleep and rest
6.select suitable clothes dress and undress
7.maintain body temperature within normal range by adjusting clothing and modifying
environment.
8. keep the body clean and well groomed and protect the integument.
9.Avoid dangers in the environment and avoid injuring others.
10. communicate with others in expressing emotions ,needs,fear, or opinions.
11.worship according to ones faith.
12.work in such a way that there is a sense of accomplihsment.
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.

ASSESSMENT OF PATIENT ON THE BASIS OF 14 BASIS COMPONENTS

 Breathe normally

- patient has difficulty in breathing especially in supine position due to ascites.

 Eat and drink adequately
- Pateint is taking so limited food.
- He has loss of appetite.
- He has restricted fluid intake.

 Eliminate body wastes

- Patient has no problem related to bladder and bowel empty but her serum
creatinine level is high.(2.ogm/dl)

 Sleep and rest

- Pateint has disturb sleep

- He has discomfort due to ascites

 Select suitable clothes-dress and undress

-patient has no significant problem in this area.

 Maintain body temperature within normal range by adjusting clothing and modifying
environment.

- Patient has sometimes mild fever.

 Keep the body clean and well groomed and protect the integument.

- Client look dirty.

- He has risk for skin break down due to edema.

 Move and maintain desirables postures

- Patient has only limited mobility.

 Avoid dangers in the environment and avoid injuring others.

- Pateint has no significant problem in these area as the environment is safe for
pateint.
 Communicate with others in expressing emotions,needs ,fears or opinions.
- Pateint communicate limited with health members because he has some language
problem,

 Worship according to ones faith

- Patient has some problem in this areas because he has no appropriate environment
for worship according to own faith.

 Work in such a way that there is a sense of accomplishment

- Patient has only limited involvement in activities of daily living.

 Play or participate in various forms of recreation

- He dose not seems to interested in recreational activities like talking to other

patient and staffs.

 Learn ,discover,or satisfy the curiousity that leads to normal development and health
and use the available health facillities.

- He is not interested to learn.he is not curious towards environment.

NURSING DIAGNOSIS

1.Ineffective tissue perfusion related to bleeding tendencies and varices that may hemorrhage

2.Ineffective breathing pattern related to ascites and restriction of thoracic excursion

secondary to ascites ,abdominal distension ad fluid in thoracic cavity as evidenced by
increase respiratory rate.

3.Activity intolerance related to lack of energy and altered respiratory function secondary to
ascites as evidenced by patient is not able to do her work without assistance.

4.Impaired skin integrity related to pruritus from jaundice and edema as evidenced by
physical examination.

5.Imbalanced nutrition less than body requirement related to abnormal bowel function as
evidenced by poor muscle tone.
6.Excess fluid volume related to compromised regulatory mechanism. (decreased plasma
protien,malnutrition.) as evidenced by edema and weight gain.

7.Disturb body image related to biophysical changes/altered physical appearnce/self

destructive behaviour(alcohol induced disease.)

8.Risk for acute confusion related to inability of liver to detoxify certain enzymes/drugs

9.Risk for injury related to portal hypertension.

10.Deficient knowledge related to information misinterpretation as evidenced by asking

frequent question.
Assessment Nursing diagnosis Goal Planning Implementation Rationale evaluation

Subjective Ineffective To maintain Monitor Monitored To obtain baseline After providing

data: breathing pattern effective respiratory respiratory data. all the nursing
related to ascites respiratory rate,depth and rate,depth and care patients
Patient said and restriction of pattern. effort. effort. breathing pattern
that I am thoracic excursion is improve
having secondary to Encourage Encouraged Aids in lung somewhat.
breathing ascites ,abdominal frequent frequent expansion and
difficulty. distension ad fluid repositioning and repositioning and mobilizing
in thoracic cavity deep breathing deep breathing secretions.
Objective data: as evidenced by exercise. exercise
increase
By assessing respiratory rate. Provide Provided To treat or
respiratory rate (24 breath/min) supplemental o2 supplemental o2 prevent hypoxia.
as indicated. as indicated.
24 brath/min
Monitor serial Moniotred ABGs Reveals changes
ABGs,and pulse and pulse in respiratory
oximetry. oximetry. status.

Demonstrate and Demonstrated and Reduces

assist with assist with incidence of
respiratory respiratory atelectasis.
adjuncts incentive adjuncts incentive
spirometer. spirometer.
Assessment Nursing diagnosis Goal Planning Implementation Rationale evaluation

Subjective data: Impaired skin To maintain skin Inspect pressure Inspected Edemateous After providing
integrity related to integrity. points and skin pressure points tissues are more all the nursing
pruritus from surfaces closely. and skin surfaces prone to care patients skin
jaundice and closely. breakdown and to is integrity is
edema as the formation of improve
evidenced by decubitus. somewhat.
physical
examination.
Objective data: Assist with active Assisted with Exercise enhance
By physical and passive ROM active and passive the circulation.
examination. exercises as ROM exercises as
appropriate. appropriate

Recommend Recommend Enhances venous

elevating lower edelevating lower return.
extremities. extremities.

Provide perineal Provided perineal Prevents skin

care following care following excoriation
urination and urination and breakdown from
bowel movement. bowel movement. bile salts.

Use calamine Used calamine May be soothing

lotion and provide lotion and provide and provide relief
baking soda bath. baking soda bath. of ithcing.
Assessment Nursing diagnosis Goal Planning Implementation Rationale evaluation

Subjective data: Excess fluid volume To stabilize fluid Measure intake Measured intake Deveoping or Aftter providing
My weight is related to volume,with and output and output resoultion of fluid all the nursing
gradually compromised balanced intake chart ,weight and chart ,weight and shifts, care fluid volume
increased. regulatory and output chart. note gain of more note gain of more is reduce
mechanism. than o.5kg/day. than o.5kg/day. somewhat.
(decreased plasma
protien,malnutrition.
Objective data: ) as evidenced by Auscultate Auscultated lungs Increase
edema and weight lungs ,noting ,noting pulmonary
By intake output gain. diminished diminished breath congestion may
chart. breath sounds sounds and result in
and developing developing consolidation.
adventitious adventitious
sound. sound.

Assess degree of Assessed degree Fluids shift into

peripheral edema. of peripheral tissues as a result
edema. of sodium and
water retention.

Measure Measured Reflects

abdominal girth. abdominal girth accumulation of
fluids.
Restrict sodium Restricted sodium To correct
and fluid as and fluid as dilutional
indicated. indicated. hyponatremia.
Assessment Nursing diagnosis Goal Planning Implementation Rationale evaluation

Subjective data: Disturb body To understanding Support and Supporet and Need to make After providing
image related to of changes and encourage pateint encourage pateint every effort to all the nursing
biophysical acceptance of self provide care with a provide care with a help patient feel care client
changes/altered in the present positive friendly positive friendly valued as understand
physical situation. attitude. attitude. aperson. somewhat about
Objective data; appearnce/self body changes.
destructive Discuss situation Discussed situation
By physical behaviour(alcohol and encourage and encourage Patient is very
examination. induced disease.) verbalization of verbalization of sensitive to body
fears and concerns. fears and concerns. changes and may
also experience
feelings of guilt
when cause is
related to alcohol
or other drug use.

Refer to support Refered to support Increased

services.counselor services.counselors vulnerability and
s ,socil service and ,socil service and concerns
alcohol treatment alcohol treatment associated with
program may help. program may help. illness may
require service of
additional
resources.
Assessment Nursing Goal Planning Implementation Rationale evaluation
diagnosis
Risk for injury Maintain Closely assess for Closely assessd for Mucosal fragility After
related to portal homeostasis signs and symptoms signs and symptoms and alteration in providing all
hypertension. with absence of of GI bleeding. of GI bleeding. hemostasis the nursing
bleeding. associated with care the risk of
cirrhosis. injury is
Observe for presence Observed for reduced.
of presence of Subacute
petechiae,ecchymosis petechiae,ecchymosi disseminated
,bleeding from one or s intravascular
More sites. ,bleeding from one or coagulation may
More sites. develop secondary to
altered clotting
factors.

In the presence of
Encourage use of soft clotting factor
toothbrush,electric Encourage use of distrubances,minimal
razor,avoiding soft Trauma can cause
straining for stool. toothbrush,electric mucosal bleeding.
razor,avoiding
straining for stool.
DIET
COMPLICATION

 Portal hypertension
 Ascites
 Hepatorenal syndrome
 Hepatic encephalopathy
 Coagulopathy
 Hepatocellular carcinoma
 Hepatopulmonary syndrome
HEALTH EDUCATION

 Don't drink alcohol. Whether your cirrhosis was caused by chronic alcohol use or
another disease, avoid alcohol. Drinking alcohol may cause further liver damage.

 Eat a low-sodium diet. Excess salt can cause your body to retain fluids, worsening
swelling in your abdomen and legs. Use herbs for seasoning your food, rather than salt.
Choose prepared foods that are low in sodium.

 Eat a healthy diet. People with cirrhosis can experience malnutrition. Combat this with
a healthy plant-based diet that includes a variety of fruits and vegetables. Choose lean
protein, such as legumes, poultry or fish. Avoid raw seafood.

 Avoid infections. Cirrhosis makes it more difficult for you to fight off infections.
Protect yourself by avoiding people who are sick and washing your hands frequently.
Get vaccinated for hepatitis A and B, influenza, and pneumonia.

 Use over-the-counter medications carefully. Cirrhosis makes it more difficult for

your liver to process drugs. For this reason, ask your doctor before taking any
medications, including nonprescription drugs. Avoid drugs such as aspirin and
ibuprofen (Advil, Motrin IB, others). If you have liver damage, your doctor may
recommend you avoid acetaminophen (Tylenol, others) or take it in low doses for pain
relief.
SUMMARY
In this assignment I had included the following topic:
 Introduction
 History collection
 Physical examination
 Investigation
 Pharmacological management
 Theory application
 Nursing process
 Diet
 complication
 Health education
 Home remedies

CONCLUSION

 Cirrhosis is a complication of liver disease that involves loss of liver cells and
irreversible scarring of the liver.
 Alcohol and viral hepatitis B and C are common causes of cirrhosis, although there
are many other causes.
BIBLIOGRAPHY
1.Black J.M & Matassarin E(1997),MEDICAL SURGICAL NURSING:Clinical
Management for continuity of care.J.B.Lippincott.co

2. Smeltzer S.C.&Bare,B(2003) BRUNNER & SUDDARTHS TEXTBOOK OF

MEDICAL SURGICAL NURSING (10th edition).

3. Brunner & siddharts, ‘’ TEXTBOOK OF MEDICAL SURGICAL NURSING’’

Jaypee Brothers medical publishers(p) LTD,13th edition

4.F.A.Davis,”DRUG GUIDE FOR NURSES,” 9th edition, Nursing Robert Martone

Publication.

5.Javed Ansari and Davinder Kaur, ‘’TEXTBOOK OF MEDICAL SURGICAL

NURSING- 1’’, first edition, pee vee publication, 2015

6.Ksum Samant,"MEDICAL SURGICAL NURSING," 3rd edition, Vora medicak

Publication.

7.Kochuthresiamma Thomas," MEDICAL SURGICAL NURSING -I," 1st edition,

Jaypee publication.
8.Ross and Wilson’’ANATOMY AND PHYSIOLOGY,” 12TH edition, jaypee
Publication.