Critical Thinking Paper
Jennifer Fisher
Grand Canyon University
NUR311
Professor Evinrude &Hemmila
October 11, 2010
Clinical Instructor: Colin
Critical Thinking Paper
Introduction
The following paper is a critical thinking paper based off of a 40 – year- old male patient that was admitted to Banner Good Samaritan’s neurology floor in October of 2010. The critical thinking skills that have been implemented are vital to the care of this patient’s acute and chronic health issues. The next step in the process of caring for this patient is to implement nursing interventions that will attend to his acute and chronic history.
Biographical Data
Patient, T.W., was admitted into room 626 on pod 6C at Banner Good Samaritan on October 6, 2010. He has been married for fifteen years to his current wife with four children. He is previously divorced and had two children with her. In total T.W. has six children, four boys and two girls (the youngest being 24 years of age). T.W. is a forty – year – old Caucasian male who was admitted to the hospital with a chief complaint of bilateral lower extremity cellulites and worsening encephalopathy per his wife. However, the patient’s more important reason for hospitalization is being in End Stage Liver Disease. His physician is Dr. Ray Quyan and several residents.
History of Present Illness
T.W.’s current diagnosis is End Stage Liver Disease pertaining to nonalcoholic steatohepatitis. He has been in and out of the hospital for the past eight years trying to get onto the national transplant list. In December of 2009 he had a CT of his abdomen with and without contrast. The results were the liver was severely nodule, there was hypertrophy of the left and caudate lobe of the liver consistent with cirrhosis. His liver has heterogeneous enhancement pattern; no hyper vascular masses or areas of abnormal venous phase washout within liver. Main portal vein dilated measuring 19 mm in diameter partial thrombus of superior mesenteric vein. There are multiple varices in the abdomen, moderate splenomegaly, and small ascites in the abdomen. Mild atelectasis at the base of his lungs. and stones in the gallbladder. Pancreas, adrenal glands, and kidneys have normal CT appearance. Mild wall thickening of right colon pertaining to the liver disease and fat containing umbilical hernia. There is moderate aortoiliac atherosclerosis bones are osteopenic. Large Schmoil’s node at superior endplate of T12. The impression is: CT evidence of cirrhosis and portal hypotension, no CT evidence of hepatocellular carcinoma, partial thrombus of superior mesenteric vein, gallstones, atherosclerosis, small fat containing umbilical hernia, and osteopenia. This round in the hospital his blood levels and decreased liver function were enough to warrant him being placed on the transplant list. He is currently on strict bed rest, due to this decreased level of activity and the pressure of his weight bearing down on his buttocks he has a minor pressure sore located just superior of the crack in his buttocks. There are no pressure sores located on his ankles, elbows, or other bony prominences that have a had a great amount of contact on his bed. T.W. had a paracentesis performed on October 04, 2010 for ascites, this removed 3.7 L from his large abdomen. There is a great possibility that he will have a paracentesis done once a week. The paracentesis worked wonderfully. The patient stated: “I can breathe a lot more easily now, I don’t feel as great a pressure”. Continued use of paracentesis until a liver transplant is available will ease the patient’s respiratory and body stress.
Health History
Past Medical History
His past medical is extremely extensive. He has had hypercholesterolemia, hyperlipidemia, hypertension, peripheral edema, sleep apnea, shortness of breath, forgetfulness, fractures, joint pain, type II diabetes, cirrhosis, diarrhea, esophageal varices, GERD, upper GI bleed, heart burn, liver disease, umbilical hernia, renal disease, urinary retention, kidney injury, skin cancer, candida under abdominal folds, anemia, bruising, pancytopenia, coagulopathy, depression, and Rubella. At home (just prior to this hospitalization) T.W. takes 40 grams of lactulose every hour on the hour. He also takes Welchol to maintain his body’s glycemic control. There is also the use of Xenaderm to increase blood flow to areas of the skin that have been injured and prevents infection.
Family Health History
Genogram
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Key: = Female Deceased
= Female Living
= Male Living = Male Deceased
Patient was unable to give more family history than that both of his parents had died from complications of hypertension and type II diabetes.
Psychosocial Health History
Psychosocial Health History
The patient states that he has a “great social life, especially when not in the hospital”. His wife stays by his bedside, however, friends, family, and his pastor visit him routinely.
Physical Examination
Neurological
T.W. is awake and oriented to place, time, and name. The patient is active with those around him and showing no signs of distress. There is no asterixis. His eyes are icteric. All extra ocular movement is intact in all directions. Photophobia is absent; gaze is conjuate. There is equal strength present in his upper extremities (+2), able to move against gravity and against light resistance (+2). There is equal strength present in his lower extremities (+1), able to move against gravity but not against resistance. All sensation is present. No deviation in his tongue is present. Speech is clear and no drooping of the face. Head movement and shoulder shrug are strong bilaterally.
Cardiac
The patient has a regular rate and rhythm present. His EKG shows a normal sinus rhythm. Looking at his chart there was a systolic murmur present. His blood pressure was 111/53 and a pulse of 72 beats per minute. Pulses were strong and equal bilaterally in the radials (+2). T.W.’s pedal pulses were very weak bilaterally (+1).
Respiratory
When listening to the patient’s lungs there was mild wheezing present upon expiration and fine crackles present in the lower and upper lobes bilaterally. The crackles, however, were more defined on the right side of the lungs. The patient presents with shortness of breath. A chest x-ray showed mild to moderate pulmonary edema and progression of the infiltrate in the upper and lower right lobe. No coughing was present in the patient. Respirations were 18 breaths per minute with an O2 saturation of 93 percent on 3.0L nasal canula. Patient uses a nasal canula during the day and at night switches to using a C-pap mask.
Gastrointestinal
Upon ascultation bowel sounds were heard present and hyperactive in all four quadrants. His belly is distended with no tympanic sounds. There is no guarding or tenderness present upon palpating. The patient has no complaints of nausea or vomiting. He had four bowel movements during my shift. All bowel movements were watering filled with dark and fatty looking stool. Abdomen is warm to touch and umbilical hernia is noted.
Genitourinary
The patient has an indwelling foley catheter. There is no irritation or signs of infection present. The drain was emptied twice during my shift. At 1100 there was 1600 ml of urine emptied and at 1700 there was another 1500 ml of urine emptied. The color was a dark yellow, no sediments or blood were present. Listed below are the intake and output recorded for two days:
I&O for 10/6/10-10/7/10: PO intake: 700ml IVPB: 100ml saline flush amount: 5ml %of meal eaten: 40 Intake total: 805ml Output: Indwelling catheter: 4,650ml Total output: 4,650ml Balance for 10/6/10-10/7/10: 3,845
I&O for 10/7/10-10/8/10: PO intake: 480ml IVPB: 100ml saline flush amount: 5ml %of meal eaten: 10 Intake total: 585ml Output: Indwelling catheter: 3100ml Total output: 3100ml Balance for 10/7/10-10/8/10: 2515
Skin
T.W.’s skin was intact but frail. There are two IVs in place: the first is a 20 gauge located peripherally on the left side, inserted on October 1, 2010. The second IV is an 18 gauge located peripherally on the right side. Both flush easily, however, the right side flushes noticeably easier than the left. Each sight shows no redness, edema, leakage, or pain. The dressings are dry and intact. There are no continuous IV infusions running at this time. T.W. presents with jaundice over the entire body and severe edema in the lower extremities. However, his wife stated that: “the edema had decreased since the day before.” There is a bed sore located in the crack of his buttocks. It is red and there is slight bleeding when the sore is agitated. Xenaderm is being used to treat the sore by promoting blood flow and protecting the area from infection. The erythema present on T.W. is also resolving.
Functional Health Pattern Assessment
Health Perception/Health Management
The patient is compliant with all medications and treatment plans. He is currently on the national transplant list waiting for a liver donation. He states that he does not smoke, participate in the use of illegal drugs, and does not drink alcohol. He and his wife are very knowledgeable about the medications he is on. If the medication is new he has no problem asking the physician or nurse about its use. Since the liver failure became more severe he has become much more incapacitated.
Values and Beliefs
He believes in God, that Jesus died and rose again for his sins. Prior to this last year, he attended church every Sunday. However, a year ago when his immune system was really struggling he stopped attending so as to not increase his factors of getting sick or obtaining infections. Now a pastor visits him and his wife twice a day.
Cognitive/Perceptual
He has a college education, graduated from ASU with a business degree. Was in the Vietnam war. He learns best by doing and reading. He and his wife in the past have always made their decisions together. However, because of the disease process and its effect on him mentally his wife is starting to make more of the decisions on her own.
Nutrition/ Metabolic
The patient would prefer to have solid foods again but he is unable to handle eating solid foods. Patient seems to be in a state of anorexia. His wife feeds him two Ensure meals every day so that he is getting some kind of nutrition. He eats around nine in the morning and again around three or four in the afternoon. The day before he was able to finish about 40 percent of his meal and today he was only able to finish about 10 percent. The patient is constantly drinking water; will go through 8-10 medium sized cups of iced-water. Financially he is stable because his wife is a real estate broker and he is a veteran from Vietnam.
Activity/Exercise
The patient is completely bed bound. No physical therapists have come to see him. T.W.’s activities of daily living are performed by his wife or the nurse on hand. He is able to open his mouth for brushing his teeth, requires full bed bath and perineal care. Has no ability to drive currently. Prior to his hospitalization he took complete care of his wife and now the roles have reversed to her caring for him.
Elimination
The patient currently has an indwelling foley catheter and is voiding well. The catheter is in place with no signs of irritation or infection. At 1100 there was 1600 ml of urine emptied and at 1700 there was another 1500 ml of urine emptied. The color was a dark yellow no sediments or blood were present. He has had four bowel movements since I was on shift. They were watery, dark and fatty looking stool.
I&O for 10/6/10-10/7/10: PO intake: 700ml IVPB: 100ml saline flush amount: 5ml %of meal eaten: 40 Intake total: 805ml Output: Indwelling catheter: 4,650ml Total output: 4,650ml Balance for 10/6/10-10/7/10: 3,845
I&O for 10/7/10-10/8/10: PO intake: 480ml IVPB: 100ml saline flush amount: 5ml %of meal eaten: 10 Intake total: 585ml Output: Indwelling catheter: 3100ml Total output: 3100ml Balance for 10/7/10-10/8/10: 2515
Sleep and Rest
The patient sleeps a great majority of the day. When people are present he is awake and active, however, once they have left exhaustion takes over. He sleeps with a C-pap, most of the time he does not mind it. Lately it has been irritating him, the night before clinical he pulled it off because it was causing him to not sleep. No use of sleep medications or aids were stated.
Role/Relationship
He is a father of six children. Two are from his previous marriage and four are from his current. All, except one, of his kids lives in Phoenix. He has been married to his current wife for fifteen years and doesn’t know what to do without her. He is veteran from Vietnam and helps his wife with keeping record of her business on the computer. Lives with his wife, has a great social system. His friends come and visit him in the hospital regularly along with their pastor who is now a dear friend of theirs. T.W. never stated or hinted at any fear of abuse or neglect.
Coping and Stress
Patient is in ESLD and extremely stressed about what his wife will do without him. He is also scared of dying. Patient prays with his wife to God when things seem out of control for them. Patient’s stress level increases greatly when his wife is not at his bedside or in the room.
Self Perception/Self Concept
The patient is extremely concerned about everything that is happening with his body. Currently he is happy to be on the transplant list but hates the waiting game. Emotionally he depends a lot on his wife, does not even want her to leave his bedside so that she can simply use the bathroom or take a shower.
Sexuality/Reproductive
His sexual life is non-existent. His being sick has put sex on hold the patient states: “I am too tired and unable to perform like a used to.”
Pathophysiology of Primary Illness
End Stage Liver Disease (ESLD) is a failure of one’s liver. It is the end of cirrhosis and requires a liver transplant in order for the patient to have any normal function of the liver. This patient’s ESLD is due to a non-alcoholic steatohepatosis, this is known as a fatty liver. The cause is a result of inflammation, obesity, high cholesterol, hypertension, type II diabetes, and cirrhosis (all of which are present in the patient’s history) (Rhodes, 2009). Symptoms include: weight loss without trying, easy bruising, nosebleeds, jaundice, abdominal pain/discomfort, fatigue, and weakness, and frequent infections (Rhodes, 2009). There is also noted confusion in the patient due to ammonia levels being high. Diagnostic test will be a CT scan, MRI, abdominal ultrasound, and a liver biopsy to verify diagnosis (Rhodes, 2009). The nurse will need to monitor respiratory system (fluid build up and infection risk increases), monitor bowel sounds, skin break down, teach family and patient coping mechanisms related to the disease process and waiting for organ transplants (Rhodes, 2009).
T.W. has a vast medical history all of which have seemed to lead up to his end stage liver disease. He is currently on the national transplant list waiting for his liver. Since he has been in the hospital his laboratory values have continued to come back towards more normal and functional levels.
Interpretations
Medication
T.W. is on strict bed-rest, because of this and the fact that he is over weight he has obtained a bed-sore near the crack of his buttocks to treat this balsam Peru (Xenaderm) is being used. This medication is a topical ointment that increases blood flow to the affected area, helps with the healing process (Skidmore-Roth, 2011). Side effects can include: sepsis, fever, chills, tachycardia, weakness, or an allergic reaction to the medication (Skidmore-Roth, 2011). Monitor the wound site paying attention for signs of infection or allergic reaction. The infection could occur because the ointment may cause sloughing of the necrotic tissue from the bed-sore. Welchol is a medication that is frequently given to T.W. in order to help with glycemic control. It’s class is antilipemic and a bile acid sequestrant whose action is to “absorbs, combines with bile acids to form insoluble complex that is excreted through feces; loss of bile acids lowers cholesterol levels” (Skidmore-Roth, 2011). Side effects for this medication can include: dizziness, vomiting, decreased vitamin K, bleeding, increased PT levels, tinnitus, and GI obstruction (Skidmore-Roth, 2011). With this strictly monitor the intake and output of the patient, potassium levels, bowel patterns, and the CNS system (looking for diminished levels of consciousness) (Skidmore-Roth, 2011). Lasix (furosemide) is a loop diuretic that “inhibits reabsorption of sodium and chloride at the proximal and distal tube and in the loops of Henle” (Skidmore-Roth, 2011). This diuretic is used to treat T.W.’s history of hypertension, as well as, treat the edema in his lower extremities. Side effects include: headache, fatigue, weakness, paresthesias, circulatory collapse, nausea, loss of hearing, polyuria, renal failure, thrombocytopenia, leukopenia, and anemia (Skidmore-Roth, 2011). With this medication monitor for metabolic alkalosis, hypokalemia, strict intake and output, respiratory system, blood pressure, his electrolyte levels, and his lower extremity edema (Skidmore-Roth, 2011). The medication Imipenem-cilastatin is an antiinfective that “interferes with cell wall replication of susceptible organisms; osmotically unstable cell wall swells, bursts from osmotic pressure” (Skidmore-Roth, 2011). This medication order is extremely hard on a patient’s hepatic system, due to that it has a five – day stretch and then the patient is placed on another antibiotic. Side effects include: fever, somnolence, seizures, confusion, palpitations, tachycardia, decreased hemoglobin and hematocrit, renal toxicity or failure, and diarrhea (Skidmore-Roth, 2011). Monitor his whit blood cell count, sputum, and temperature (a sign of infection), any allergic reaction (especially since the patient is allergic to penicillin he will have an increased sensitivity to this medication), bowel movements (since diarrhea is also a sign of infection) (Skidmore-Roth, 2011). This patient was also receiving three doses of lacutlose, two were given at 0800 and 1200 for 90Gm and a third was given at 1600 for 20Gm of the syrup. Lactulose is a laxative that “prevents the absorption of ammonia in colon by acidifying stool; increases water in stool” (Skidmore-Roth, 2011). T.W. receives this medication to hopefully control his ammonia levels and to also treat any constipation he may have due to stress and from his disease process. Side effects include: nausea, vomiting, anorexia, diarrhea, hypernatremia, and distension (Skidmore-Roth, 2011). In monitoring this patient watch the amount, color, and consistency of the stool that is being expelled (Skidmore-Roth, 2011). Also, monitor the patient’s electrolyte levels, strict intake and output records, pay attention for nausea and vomiting, and close attention to his mental status (confusion, lethargy, or irritability) (Skidmore-Roth, 2011). Nadolol is an antihypertensive or beta-adrenergic receptor blocker that is “long acting, nonselective beta adrenergic receptor blocking agent, blocks B1 in the heart and B2 in the lungs, uterus, and circulatory system; similar to propranolol” (Skidmore-Roth, 2011). This beta – blocker is used as a treatment for the patient’s hypertension. The side effects include: depression, dizziness, fatigue, bradycardia, hypotension, nausea and vomiting, blurred vision, dyspnea, diarrhea, and respiratory dysfunction (Skidmore-Roth, 2011). For T.W. monitor his blood pressure, pulse, cardiac system, record intake and output strictly, monitor for dyspnea, vein distention, and any CNS changes (Skidmore-Roth, 2011). Another type of medication used is an antifungal or amphoteric polyene called Nystatin. This medication “interferes with fungal DNA replication; binds sterols in fungal cell membrane, which increases permeability, leaking of cell nutrients” (Skidmore-Roth, 2011). This topical powder is used to treat the patient’s candida that is located near his perineal area and under the skin folds of his lower stomach. Side effects may consist of: headache, insomnia, pneumonia, hyperglycemia, and abdominal pain (Skidmore-Roth, 2011). In this patient monitor bowel sounds, AST and ALT levels, and monitor for vitamin B12 deficiency (Skidmore-Roth, 2011). Pantoprazole (Protonix) is a medication used to treat the patient’s GERD. It is a proton pump inhibitor (benzimidazole), its action is to “suppress gastric secretion by inhibiting hydrogen/potassium ATPase enzyme system in gastric parietal cell; characterized as gastric acid pump inhibitor, since it blocks final step of acid production” (Skidmore-Roth, 2011). Side effects include: headache, insomnia, pneumonia, hyperglycemia, and abdominal pain (Skidmore-Roth, 2011). Monitor his bowel sounds, AST and ALT levels, also be monitoring the patient’s vitamin B 12 for deficiency (Skidmore-Roth, 2011). The next medication, Potassium chloride, is used to treat T.W.’s hypokalemia. It is known as an electrolyte or mineral replacement that is needed for adequate transmission of nerve impulses and cardiac contraction, renal function intracellular ion maintenance” (Skidmore-Roth, 2011). Side effects may include: bradycardia, dysrrhythmias, nausea and vomiting, oliguria, cold extremeties, diarrhea, pain, and ulceration of the small bowel (Skidmore-Roth, 2011). For this patient we want to monitor the potassium levels, intake and ouput, the cardiac system (Skidmore-Roth, 2011). Rifaximin (Xifaxan) is an antiinfective that “binds to bacterial DNA dependent RNA polymerase, thereby inhibiting bacterial RNA synthesis” (Skidmore-Roth, 2011). The patient T.W. received it twice a day to treat his diarrhea. Side effects of this medication are: dizziness, constipation, nausea and vomiting, headache, pyrexia, motion sickness, tinnitus, rectal tenesmus, abdominal pain, and insomnia (Skidmore-Roth, 2011). Monitor the GI tract (Skidmore-Roth, 2011). Ciprofloxacin is also an antiinfective (fluoroquinolone) whose action is to “interfere with the conversion of intermediate DNA fragments into high molecular-weight DNA in bacteria; DNA gyrase inhibitor” (Skidmore-Roth, 2011). This medication is used profilactily for the patient It helps prevent infection in the patient, especially since he is in organ failure and on the organ transplant list. Due to him being on this list and receiving paracentesis treatments it is crucial that he remain infection free. Side effects for Ciprofloxacin include: headache, dizziness, fatigue, restlessness, seizures, diarrhea, increased ALT levels, visual impairment, pruritus, and oral candidiasis (Skidmore-Roth, 2011). It is essential to monitor for infection (through WBC, fever, etc…), CNS symptoms, BUN, creatinine, AST and ALT levels, and depression (Skidmore-Roth, 2011). Insulin lispro is an anti diabetic (pancreatic hormone) that “decreases blood glucose; by transport of glucose into cells and the conversion of glucose to glycogen, indirectly increases blood pyruvate and lactate, decreases phosphate and potassium” (Skidmore-Roth, 2011). This is used to manage T.W.’s type II diabetes. His glucose is measured before each meal, if his body mass index is greater than 30 he receives the Insulin lispro three times a day before meals, as needed. This patient before his breakfast received three units. Side effects can include: blurred vision, dry mouth, urticaria, peripheral edema, hypoglycemia, lipohypertrophy, swelling, and redness (Skidmore-Roth, 2011). Monitor his blood glucose levels, urine ketones, and look for signs of hyperglycemia (nausea and vomiting, weakness, glycosuria, increased urination, etc…) (Skidmore-Roth, 2011). Tramadol is an analgesic that “binds to opioid receptors, inhibits reuptake of norepinephrine, serotonin” (Skidmore-Roth, 2011). This is used to treat the patient’s mild to severe pain levels. Side effects that are possible are: CNS stimulation, orthostatic hypotension, confusion, anxiety, constipation, nausea and vomiting, urinary retention/frequency, and pruritus (Skidmore-Roth, 2011). For T.W. strictly monitor his intake and output, pain levels, bowel pattern, and any CNS or levels of consciousness changes (Skidmore-Roth, 2011).
Laboratory
The patient’s laboratory values have been very interesting to watch. When he came in most of the lab values were out of normal ranges because he was not receiving the level of treatment he needed in order to come close to maintaining those levels. Since he has been here for almost a week now his labs are now starting to make an adjustment and are slowly making their way to an acceptable level. His hematocrit count starting on October 4, 2010 went from 22.5 % to 23.2 % on the fifth of October and was sitting at 24.5 on October 6, 2010. While hematocrit count was rising, the decreased level is indicative of anemia, cirrhosis, and renal disease (Pagana, & Pagana, 2006). His hemoglobin also has the same trend. Starting at 7.9 moves to 8.1 and on the sixth of October is at an 8.6 g/dL. These low levels are also indicative of anemiz, cirrhosis, and renal disease (Pagana, & Pagana 2006). Other labs including RBC count starts at 2.35 moves to 2.43, and morning labs on the sixth show results at 2.54. These labs show indications of possible dietary deficiency and organ failure (Pagana, & Pagana 2006). Both of those indications are correct, the patient continues to decrease his intake of nutrients and his liver is failing. T.W.’s potassium levels were slightly decreased as well, 3.1, 3.0, and 3.2 over a three - day span. This decrease is due to severe diarrhea and a deficient intake of dairy (Pagana, & Pagana 2006). His CO2 levels are also low: 14, 16, and 21 mEq/L over a three – day span. This is indicative of fluid loss from diarrhea and renal insufficiency (Pagana, & Pagana 2006). The patient’s BUN is extremely elevated on October 4 it was a 45, on the fifth it was 42, and on the sixth it was 40 mg/dL. These elevated levels are indicative of congestive heart failure and sepsis (Pagana, & Pagana 2006). The Pro-Time and INR levels are both elevated. Pro-Time for the fourth is 27.6 and moves to 25.9 on the sixth of October. The INR sit at 2.6 for the fourth and moves to 2.4 on October 6th. Both of these elevated blood tests are indicative of liver disease and a vitamin – K deficiency (Pagana, & Pagana 2006). There was no PTT performed on the patient. The laboratory levels for his platelet count are severely diminished 62 on the fourth of October, morning labs for the fifth of October were 76, and 83 for the sixth of October. These low levels show signs of anemia or of an infection (Pagana, & Pagana 2006). Another abnormal lab value is the albumin, starting at 3.4 it decreases to 3.3 and morning labs on the sixth of October are 3.1g/dL. These low levels are indicative of malnutrition, cirrhosis, and malabsorption (Pagana, & Pagana, 2006). The bilirubin levels are all extremely elevated in this patient, 7.4 on the fourth of October, 7.2 on the fifth, and 6.5mg/dL for the sixth of October. These increased levels are indicative of anemia, hepatitis, cirrhosis, or sepsis (Pagana, & Pagana, 2006). T.W.’s ABGs are indicative of metabolic acidosis with compensation of the respiratory system (Pagana, & Pagana, 2006). The pH was 7.328, pCO2 was 33.6, pO2 was 86.5, and his HCO3 was 17.1. His WBC, Na, CL, and creatinine levels were all within the normal range subscribed for each.
Diagnostic Tests
In December of 2009 he had a CT of his abdomen with and without contrast. The results were the liver was severely nodule, there was hypertrophy of the left and caudate lobe of the liver consistent with cirrhosis. His liver has heterogeneous enhancement pattern; no hyper vascular masses or areas of abnormal venous phase washout within liver. Main portal vein dilated measuring 19 mm in diameter partial thrombus of superior mesenteric vein. There are multiple varices in the abdomen, moderate splenomegaly, and small ascites in the abdomen. Mild atelectasis at the base of his lungs. and stones in the gallbladder. Pancreas, adrenal glands, and kidneys have normal CT appearance. Mild wall thickening of right colon pertaining to the liver disease and fat containing umbilical hernia. There is moderate aortoiliac atherosclerosis bones are osteopenic. Large Schmoil’s node at superior endplate of T12. The impression is: CT evidence of cirrhosis and portal hypotension, no CT evidence of hepatocellular carcinoma, partial thrombus of superior mesenteric vein, gallstones, atherosclerosis, small fat containing umbilical hernia, and osteopenia. There are no recent CT scans of his abdomen. During this hospital visit T.W. had several CTs and ultrasounds done of the liver, both showing fatty liver. A liver biopsy was also performed in one of his prior visits that verified the disease as nonalcoholic steatohepatitis (NASH). For this patient improvement is unlikely without a liver transplant. The goal is to keep him from obtaining any infections and bilirubin levels decrease. When auscultating the patient’s lungs diminished crackling sounds indicate that the diuretics are working and that the fluid built up from the organ failure is diminishing.
Truth Seeking and Analyticity
Cluster #1
- Strict bed rest
- Obesity
- Severe edema and diarrhea
- Bed sore
This cluster reflects the frailty of T.W.’s skin during this current condition in his life. Effectively, because of his size and the disease process his skin is at a great risk for continued/worsening break down.
Cluster #2
- O2 sats 93% on 3.0 L using nasal canula
- Crackles present
- Wheezing upon expiration
- Shortness of Breath
This cluster reflects the difficulty to which the patient is breathing. While no accessory muscles are being used with respirations, the respiratory system is of great concern because it shows the continued disease process.
Cluster #3
- Anorexia
- Consuming 40 and 10 percent of meals currently
- Abnormal intake and output levels
- End Stage Liver Disease
This patient continued with each meal to consume less than the previous. It took his wife and several nursing staff to convince him to finish an Ensure meal. He would state that he was “no longer hungry” after barely half the Ensure shake was finished. The malnutrition is being caused by the ESLD.
This cluster reflex
Cluster #4
- Paracentesis of 3.7L
- Distended abdomen
- End Stage Liver Disease
- Crackles in lungs upon ascultation
The patient’s ESLD is affecting his the amount of fluid that is building in the patient’s body, especially his abdomen and lungs. As the disease progresses the lungs have continued to fill with fluid.
Nursing Diagnosis One
Patient is at increased risk for continued impaired skin integrity as is evidence by strict bed rest, obesity, severe edema, diarrhea, and open bed sore.
Nursing Diagnosis Two
Patient is at risk for impaired gas exchange as is evidence by decreased O2 saturation, shortness of breath, presence of crackles when lungs are ascultated, and wheezing upon expiration.
Nursing Diagnosis Three
Patient is at risk for imbalance nutrition (less than what body requires) as is evidence by anorexia, malabsorption, End Stage Liver Disease, and abnormal intake and output levels.
Nursing Diagnosis Four
Patient is at risk for excess fluid volume as is evidence by abnormal intake and output levels, distended abdomen, crackles in lungs, and paracentesis procedure being performed weekly.
Priority Nursing Diagnoses
After great consideration the Nursing Diagnosis 4 would be of highest priority. The abdominal distention of the patient is increasing his anorexic feeling. The fluid build up in his lungs causes an increased risk for further infections like pneumonia and is also causing him to have shortness of breath. Along with this there is severe edema in his lower extremities that have put him on diuretics, leading to electrolyte imbalances and abnormal intake and output levels. The second highest priority would be Nursing Diagnosis 3 – imbalanced nutrition. The decreased appetite and malabsorption is spurred on by the disease process with continued fluid build up in the abdomen. This puts the patient at high risks for infection. The next nursing diagnosis of importance is Nursing Diagnosis 1 - Patient is at increased risk for continued impaired skin integrity as is evidence by strict bed rest, obesity, severe edema, diarrhea, and open bed sore. Followed by Nursing Diagnosis 2- impaired gas exchange.
Open-mindedness
NANDA
Outcome #1
The patient will maintain adequate fluid balance as is evidenced by clear lung sounds, resolution of severe edema in lower extremeties, decreased distention, and electrolyte levels being balanced.
Intervention A: Continue use of diuretics with patient, monitoring fluid and electrolyte levels (Swearineng, 2008).
Rationale: Continued use of diuretics will help the body to expel built up fluid (Swearineng, 2008).
Intervention B: Apply antiembolism devices upon patient as ordered (Swearineng, 2008).
Rationale: These will help to increase circulation and venous return, thus decreasing fluid in the lower extremities (Swearineng, 2008).
Outcome #2
While in the hospital patient’s severe edema will decrease and abdominal distention will be minimal
Intervention A: Patient will be taught the importance of daily weight, use of same scale, and monitoring his intake and output (Swearineng, 2008).
Rationale: By monitoring these daily, shifts in electrolytes will be able to be more predictable (Swearineng, 2008).
Intervention B: Monitor patient for presence of edema through palpation.
Rationale: The monitoring of edema will show improvement or failure of medications/treatments being received (Swearineng, 2008).
Outcome #3
By the end of the day the patient will have decreased wheezing and crackles present. Intervention A: The nurse will keep the patient on a 2 Gm sodium diet (Swearineng, 2008).
Rationale: This will decrease the patient’s intake of sodium and help to elevate fluid retention (Swearineng, 2008).
Intervention B: Patient will be taught the importance of deep breathing and coughing, as well as, the use of an incentive sphirometer (Swearineng, 2008).
Rationale: In teaching the patient this they are able decrease fluid retention in lungs.
NANDA
Outcome #1
The patient will increase from two Ensure meal replacements to three Ensure meals by the end of the day (24hr period).
Intervention A: The nurse will encourage small frequent intakes of the meals (Swearineng, 2008).
Rationale: By taking small frequent consumptions of the meal the patient will receive nutrients without overloading his system (Swearingen, 2008).
Intervention B: The nurse will encourage bringing in of his favorite foods for the patient (Swearingen, 2008).
Rationale: Through this the patient is more likely to consume food that he loves, thus increasing his nutrient intake (Swearingen, 2008).
Outcome #2
Patient will maintain stable weight upon being discharged.
Intervention A: Monitor patient intake and output strictly (Swearingen, 2008).
Rationale: This helps to decide whether the patient will need further consultations in weight management, as well as, education from a nutritionist (Swearingen, 2008).
Intervention B: Encourage small frequent meals for the patient (Swearingen, 2008).
Rationale: In doing this, the patient is able to maintain energy for other activities (ie: ADLs and maintenance of oxygen levels) (Swearingen, 2008).
Outcome #3
Patient will be eating solid food within three weeks and prior to being discharged.
Intervention A: The nurse will promote continued bed rest. (Swearingen, 2008).
Rationale: Through this the patient is able to reduce the metabolic demands that are placed upon the liver (Swearingen, 2008).
Intervention B: The nurse will encourage small frequent intakes of the meals. (Swearingen, 2008).
Rationale: By taking small frequent consumptions of the meal the patient will receive nutrients without overloading his system (Swearingen, 2008).
Conclusion
This patient unfortunately because of his disease history and his current disease process is waiting for a liver transplant. Without this transplant it is not likely that he will have any signs of improvement. His ADL’s are already dependant upon his wife and will continue to weigh on her as he worsens. There was time spent educating the patient and his wife about all the medications he is on, what to expect as the liver failure continues, and how to cope (support groups).
References
Pagana, K.D., & Pagana, T.J. (2006). Mosby’s manual of diagnostic and laboratory tests. St. Louis, Missouri: Mosby Elsevier.
Rhodes, Monica Nonalcoholic Steatohepatitis (NASH). (updated: July 15, 2009). WebMD Medical Reference from Healthwise. viewed at http://www.webmd.com/digestive-disorders/tc/nonalcoholic-steatohepatitis-nash-overview Viewed October 10, 2010.
Skidmore-Roth, L. (24th Edition, 2011). Mosby’s nursing drug reference. St. Lousi, Missouri: Mosby Elsevier.
Swearingen, P.L. All-in-one: care planning resource. (2nd Edition, 2008) St. Lousi, Missouri: Mosby Elsevier.
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