CIRRHOSIS-CASE-STUDY-HELP

Primary Concept Nutrition Interrelated Concepts (In order of emphasis) 1. Fluid and Electrolyte Balance 2. Perfusion 3. Cognition 4. Addiction 5. Clinical Judgment 6. Patient Education 7. Communication 8. Collaboration © 2016 Keith Rischer/www.KeithRN.com UNFOLDING Reasoning Case Study: STUDENT Cirrhosis History of Present Problem: John Richards is a 45-year-old male who presents to the emergency department (ED) with abdominal pain and worsening nausea and vomiting the past three days that have not resolved. He is feeling more fatigued and has had a poor appetite the past month. He denies any ETOH (alcohol) intake the past week, but admits to episodic binge drinking on most weekends. John weighs 150 pounds (68.2 kg) and is 6'0" (BMI 17.6). You are the nurse responsible for his care. Personal/Social History: John is single, has never married, and lives alone in his own apartment. He has struggled with heroin use/abuse in the past, but has not used in the past two years. John is currently unemployed and has no health insurance. He was diagnosed with hepatitis C ten years ago but has had minimal follow-up medical care since. What data from the histories are RELEVANT and have clinical significance to the nurse? RELEVANT Data from Present Problem: Clinical Significance: Abdominal pain Nausea and vomiting S/S cirrhosis Risk for hypovolemia/ F+E imbalance Fatigue poor appetite Alcohol can be a causative factor Malnutrition episodic binge drinking BMI 17.6 ALT Value: 128 Critical Value: Greater than 100 Displays liver function Manage underlying cause of alteration- alcohol Corticosteroids may reduce inflammation monitor liver enzyme lab values & for jaundice, check patient’s medication profile for liver toxic medications- NSAIDs A low-protein diet may be in order if the patient’s liver has lost the ability to process the end products of protein metabolism Clinical Reasoning Begins… 1. What is the primary problem that your patient is most likely presenting with? Liver cirrhosis 2. What is the underlying cause/pathophysiology of this primary problem? Alcohol abuse, NSAID use, and Hx of Hep C. (I.V drug abuse) Pathology: Chronic/progressive disease characterized by degeneration of hepatocytes. This destruction then causes fibrosis of the liver causing destruction of liver lobules, leading to other complications. Collaborative Care: Medical Management Care Provider Orders: Rationale: Expected Outcome: Establish peripheral IV NS 0.9% bolus of 1000 mL Ondansetron 4 mg IV every 4 hours PRN Orthostatic BP Risk for deficient fluid volume related to fluid shifts as evidence by ascites and dry lips/mucus membranes Decreased nausea Orthostatic hypotension can be a sign of dehydration Pt maintains normal fluid volume as evidence by systolic BP higher than 90, or Pt baseline, absence of orthostatic hypotension, HR 60100 BPM, urine output greater than 30 ml/hr., moist mucus membranes