lOMoARcPSD|6070128
Cirrhosis
JohnvRichards,v45vyearsvold
Primary Concept v
Nutrition
Interrelated Concepts (In order of emphasis)
v v v v v
1. FluidvandvElectrolytevBalance
2. Perfusion
3. Cognition
4. Addiction
5. ClinicalvJudgment
6. PatientvEducation
7. Communication
8. Collaboration
©v2016vKeithvRischer/www.KeithRN.com
UNFOLDINGvReasoningvCasevStudy:vSTUDENT
Cirrhosis
History of Present Problem:
v v v
JohnvRichardsvisvav45-year-
oldvmalevwhovpresentsvtovthevemergencyvdepartmentv(ED)vwithvabdominalvpainvandvworseningvnauseavandvvomitingvthevpastv
threevdaysvthatvhavevnotvresolved.vHevisvfeelingvmorevfatiguedvandvhasvhadvavpoorvappetitevthevpastvmonth.vHevdeniesvanyvETO
Hv(alcohol)vintakevthevpastvweek,vbutvadmitsvtovepisodicvbingevdrinkingvonvmostvweekends.vJohnvweighsv150vpoundsv(68.2vkg
)vandvisv6'0"v(BMIv17.6).vYouvarevthevnursevresponsiblevforvhisvcare.
Personal/Social History:
v
, lOMoARcPSD|6070128
Johnvisvsingle,vhasvnevervmarried,vandvlivesvalonevinvhisvownvapartment.vHevhasvstruggledvwithvheroinvuse/abusevinvthevpast,vb
v
utvhasvnotvusedvinvthevpastvtwovyears.vJohnvisvcurrentlyvunemployedvandvhasvnovhealthvinsurance.vHevwasvdiagnosedvwithvhep
atitisvCvtenvyearsvagovbutvhasvhadvminimalvfollow-upvmedicalvcarevsince.
WhatvdatavfromvthevhistoriesvarevRELEVANTvandvhavevclinicalvsignificancevtovthevnurse?
RELEVANTvDatavfromvPresentvProblem: ClinicalvSignificance:
AbdominalvpainvNause S/Svcirrhosis
avandvvomitingvFatiguev Riskvforvhypovolemia/vF+EvimbalancevAlcoh
poor olvcanvbevavcausativevfactorvMalnutrition
appetite
episodicvbingevdrinkingvBM
Iv17.6
RELEVANTvDatavfromvSocialvHistory: ClinicalvSignificance:
LivesvalonevUnemploy PossiblyvnovsupportvsystemvHe
ed pvC-vriskvfactor
PastvDxvofvHepvC.
WhatvisvthevRELATIONSHIPvofvyourvpatient’svpastvmedicalvhistoryv(PMH)vandvcurrentvmeds?
(Whichvmedicationvtreatsvwhichvcondition?vDrawvlinesvtovconnect.)
PMH: HomevMeds: Pharm.vClassification: ExpectedvOutcome:
*HepatitisvC– Ibuprofenv600vmgvPOvprnvfo NSAID Painvrelief
pastvhistoryvofvIVvdrugvabuse rvheadache
*ETOHvabusevxv25vyears
Onevdiseasevprocessvoftenvinfluencesvthevdevelopmentvofvothervillnesses.vBasedvonvyourvknowledgevofvpathophysiology
,v(ifvapplicable),vwhichvdiseasevlikelyvdevelopedvFIRSTvthatvcreatedvav“dominoveffect”vinvhis/hervlife?
• BOLDvthevPMHvproblemvthatvlikelyvstartedvFIRST.
• UnderlinevthevPMHvproblem(s)vFOLLOWEDvasvdomino(s).
Patient Care Begins:
v v
CurrentvVS: P-Q-R-S-TvPainvAssessmentv(5thvVS):
T:v100.5vF/38.1vCv(oral) Provoking/Palliative: Nothing/nothing
P:v110v(regular) Quality: Ache
R:v20 Region/Radiation: RUQ/epigastric
BP:v128/88 Severity: 6/10
O2vsat:v95%vRA Timing: Continuous
OrthostaticvBP’s:
Position: HR: BP:
Lying 110 128/88
Standing 132 124/80
WhatvVSvdatavarevRELEVANTvandvmustvbevrecognizedvasvclinicallyvsignificantvbyvthevnurse?
RELEVANTvVSvData: Rationale:
TempvPul Elevated-vinfection
sevratevR Tachycardiavd/tvPain-
R vsomethingvisvwrong,vdehydrationvRRvhighvendvofvnormal-
PainvOrthostati vcontinuevtovmonitor
cvBP PainvinvRUQ-
vlivervorvgallbladdervOrtho.vMild.vHRvc
hangedvbyv22
CurrentvAssessment:
GENERAL Appearsvuncomfortable,vbodyvtense,voccasionalvfacialvgrimacing
APPEARANCE:
RESP: Breathvsoundsvclearvwithvequalvaerationvbilaterally,vnon-laboredvrespiratoryveffort
CARDIAC: Pink,vwarmv&vdry,1+vpittingvedemavlowervextremities,vheartvsoundsvregular–
S1S2,vpulsesvstrong,vequalvwithvpalpationvatvradial/pedal/post-tibialvlandmarks
Cirrhosis
JohnvRichards,v45vyearsvold
Primary Concept v
Nutrition
Interrelated Concepts (In order of emphasis)
v v v v v
1. FluidvandvElectrolytevBalance
2. Perfusion
3. Cognition
4. Addiction
5. ClinicalvJudgment
6. PatientvEducation
7. Communication
8. Collaboration
©v2016vKeithvRischer/www.KeithRN.com
UNFOLDINGvReasoningvCasevStudy:vSTUDENT
Cirrhosis
History of Present Problem:
v v v
JohnvRichardsvisvav45-year-
oldvmalevwhovpresentsvtovthevemergencyvdepartmentv(ED)vwithvabdominalvpainvandvworseningvnauseavandvvomitingvthevpastv
threevdaysvthatvhavevnotvresolved.vHevisvfeelingvmorevfatiguedvandvhasvhadvavpoorvappetitevthevpastvmonth.vHevdeniesvanyvETO
Hv(alcohol)vintakevthevpastvweek,vbutvadmitsvtovepisodicvbingevdrinkingvonvmostvweekends.vJohnvweighsv150vpoundsv(68.2vkg
)vandvisv6'0"v(BMIv17.6).vYouvarevthevnursevresponsiblevforvhisvcare.
Personal/Social History:
v
, lOMoARcPSD|6070128
Johnvisvsingle,vhasvnevervmarried,vandvlivesvalonevinvhisvownvapartment.vHevhasvstruggledvwithvheroinvuse/abusevinvthevpast,vb
v
utvhasvnotvusedvinvthevpastvtwovyears.vJohnvisvcurrentlyvunemployedvandvhasvnovhealthvinsurance.vHevwasvdiagnosedvwithvhep
atitisvCvtenvyearsvagovbutvhasvhadvminimalvfollow-upvmedicalvcarevsince.
WhatvdatavfromvthevhistoriesvarevRELEVANTvandvhavevclinicalvsignificancevtovthevnurse?
RELEVANTvDatavfromvPresentvProblem: ClinicalvSignificance:
AbdominalvpainvNause S/Svcirrhosis
avandvvomitingvFatiguev Riskvforvhypovolemia/vF+EvimbalancevAlcoh
poor olvcanvbevavcausativevfactorvMalnutrition
appetite
episodicvbingevdrinkingvBM
Iv17.6
RELEVANTvDatavfromvSocialvHistory: ClinicalvSignificance:
LivesvalonevUnemploy PossiblyvnovsupportvsystemvHe
ed pvC-vriskvfactor
PastvDxvofvHepvC.
WhatvisvthevRELATIONSHIPvofvyourvpatient’svpastvmedicalvhistoryv(PMH)vandvcurrentvmeds?
(Whichvmedicationvtreatsvwhichvcondition?vDrawvlinesvtovconnect.)
PMH: HomevMeds: Pharm.vClassification: ExpectedvOutcome:
*HepatitisvC– Ibuprofenv600vmgvPOvprnvfo NSAID Painvrelief
pastvhistoryvofvIVvdrugvabuse rvheadache
*ETOHvabusevxv25vyears
Onevdiseasevprocessvoftenvinfluencesvthevdevelopmentvofvothervillnesses.vBasedvonvyourvknowledgevofvpathophysiology
,v(ifvapplicable),vwhichvdiseasevlikelyvdevelopedvFIRSTvthatvcreatedvav“dominoveffect”vinvhis/hervlife?
• BOLDvthevPMHvproblemvthatvlikelyvstartedvFIRST.
• UnderlinevthevPMHvproblem(s)vFOLLOWEDvasvdomino(s).
Patient Care Begins:
v v
CurrentvVS: P-Q-R-S-TvPainvAssessmentv(5thvVS):
T:v100.5vF/38.1vCv(oral) Provoking/Palliative: Nothing/nothing
P:v110v(regular) Quality: Ache
R:v20 Region/Radiation: RUQ/epigastric
BP:v128/88 Severity: 6/10
O2vsat:v95%vRA Timing: Continuous
OrthostaticvBP’s:
Position: HR: BP:
Lying 110 128/88
Standing 132 124/80
WhatvVSvdatavarevRELEVANTvandvmustvbevrecognizedvasvclinicallyvsignificantvbyvthevnurse?
RELEVANTvVSvData: Rationale:
TempvPul Elevated-vinfection
sevratevR Tachycardiavd/tvPain-
R vsomethingvisvwrong,vdehydrationvRRvhighvendvofvnormal-
PainvOrthostati vcontinuevtovmonitor
cvBP PainvinvRUQ-
vlivervorvgallbladdervOrtho.vMild.vHRvc
hangedvbyv22
CurrentvAssessment:
GENERAL Appearsvuncomfortable,vbodyvtense,voccasionalvfacialvgrimacing
APPEARANCE:
RESP: Breathvsoundsvclearvwithvequalvaerationvbilaterally,vnon-laboredvrespiratoryveffort
CARDIAC: Pink,vwarmv&vdry,1+vpittingvedemavlowervextremities,vheartvsoundsvregular–
S1S2,vpulsesvstrong,vequalvwithvpalpationvatvradial/pedal/post-tibialvlandmarks
