CIRRHOSIS-CASE-STUDY-HELP

Cirrhosis CIRRHOSIS-CASE-STUDY-HELP John Richards, 45 years old 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 RELEVANT Data from Social History: Clinical Significance: Lives alone Unemployed Past Dx of Hep C. Possibly no support system Hep C- risk factor What is the RELATIONSHIP of your patient’s past medical history (PMH) and current meds? (Which medication treats which condition? Draw lines to connect.) PMH: Home Meds: Pharm. Classification: Expected Outcome: *Hepatitis C–past history of IV drug abuse *ETOH abuse x 25 years Ibuprofen 600 mg PO prn for headache NSAID Pain relief One disease process often influences the development of other illnesses. Based on your knowledge of pathophysiology, (if applicable), which disease likely developed FIRST that created a “domino effect” in his/her life? • BOLD the PMH problem that likely started FIRST. • Underline the PMH problem(s) FOLLOWED as domino(s). Patient Care Begins: Current VS: P-Q-R-S-T Pain Assessment (5th VS): T: 100.5 F/38.1 C (oral) Provoking/Palliative: Nothing/nothing P: 110 (regular) Quality: Ache R: 20 Region/Radiation: RUQ/epigastric BP: 128/88 Severity: 6/10 O2 sat: 95% RA Timing: Continuous Orthostatic BP’s: Position: HR: BP: Lying 110 128/88 Standing 132 124/80 What VS data are RELEVANT and must be recognized as clinically significant by the nurse? RELEVANT VS Data: Rationale: Temp Pulse rate RR Pain Orthostatic BP Elevated- infection Tachycardia d/t Pain- something is wrong, dehydration RR high end of normal- continue to monitor Pain in RUQ- liver or gallbladder Ortho. Mild. HR changed by 22 Current Assessment: GENERAL APPEARANCE: Appears uncomfortable, body tense, occasional facial grimacing RESP: Breath sounds clear with equal aeration bilaterally, non-labored respiratory effort CARDIAC: Pink, warm & dry,1+ pitting edema lower extremities, heart sounds regular–S1S2, pulses strong, equal with palpation at radial/pedal/post-tibial landmarks NEURO: Alert & oriented to person, place, time, and situation (x4) GI: Abdomen distended, large–rounded–firm to touch, bowel sounds audible per auscultation in all 4 quadrants GU: Voiding without difficulty, urine clear/light orange, loss of pubic hair SKIN: Skin integrity intact, color normal for patient, sclera of eyes light yellow in color, lips and oral mucosa tacky dry, softball-sized ecchymosis on abdomen What assessment data are RELEVANT and must be recognized as clinically significant by the nurse? RELEVANT Assessment Data: Rationale: Uncomfortable, tense, grimacing +1 pitting edema Distended, round, firm abdomen Light orange urine + Sclera of eyes is yellow Loss of pubic hair Dry lips and mucus membranes Ecchymosis Pain Edema r/t ↓ albumin - ↓ oncotic pressure – third spacing Ascites Jaundice - ↑ bilirubin ↑ estrogen (liver not metabolizing) Dehydration r/t third spacing Bleeding – variceal hemorrhage – varices – decreased production of clotting factors Lab Results: Complete Blood Count ( CBC:)ClinicaSl ignificance:Current: High/Low/WNL? Previous: TREN D: e/Worsening/Stable: WBC (4.5–11.0 mm 3) 12.8 H 9.5 Improv Hgb (12–16 g/dL) 10.2 L 11.2 Platelets (150-450 x103/µl ) 98 L 122 Neutrophil % (42–72) 88 H 75 Band forms (3–5%) 3 H 0 RELEVANT Lab(s): WBC Neuts Bands Hgb PLT Infection Infection Infection Decreased production – risk for bleeding – oxygen carrying capacity Decreased production – risk for bleeding Worsened Worsened Worsened Worsened Worsened Basic Metabolic Panel (BMP:) Current: High/Low/WNL? Previous: Sodium (135–145 mEq/L) 135 Low end of normal 138 Potassium (3.5–5.0 mEq/L) 3.5 Low end of normal 3.8 Glucose (70–110 mg/dL) 78 WNL 88 BUN (7–25 mg/dl) 38 High 25 Creatinine (0.6–1.2 mg/dL) 1.5 High 1.1 What lab results are RELEVANT and must be recognized as clinically significant by the nurse? RELEVANT Lab(s): Clinical Significance: TREND: Improve/Worsening/Stable: Na+ Low end of normal- risk for electrolyte imbalance- continue to Worsening K+ monitor Worsening BUN High r/t third spacing and not being filtered/perfused through the Worsening Worsening Cr kidneys Coags: Current: High/Low/WNL? Previous: PT/INR (0.9–1.1 nmol/L) 1.5 High 1.2 RELEVANT Lab(s): Clinical Significance: TREND: Improve/Worsening/Stable: PT/INR: 1.5 High- bleeding risk – decreased production of clotting factors from liver UP…worsening Liver Function Test (LFT:) Current: High/Low/WNL? Previous: Albumin (3.5–5.5 g/dL) 2.5 Low 2.9 Total Bilirubin (0.1–1.0 mg/dL) 4.2 High 2.2 Alkaline Phosphatase male: 38–126 U/l female: 70–230 U/l 285 High 155 ALT (8–20 U/L) 128 High 65 AST (8–20 U/L) 124 High 85 Misc. Labs: Ammonia (11–35 mcg/dL) 35 High end of normal 28 What lab results are RELEVANT and must be recognized as clinically significant by the nurse? RELEVANT Lab(s): Clinical Significance: TREND: Improve/ Worsening/ Stable: Albumin Bilirubin Alk. Phos. ALT+AST Ammonia Low d/t ↓ production of liver- can cause fluid shifts to tissues High albumin levels indicate improper functioning of the liver to conjugate it High because kidney is not excreting Liver enzymes elevated d/t release from damaged liver cells. ALT is more specific. Ammonia building up- not being converted to urea and being excreted Worsening Worsening Worsening Worsening Worsening Lab Planning: Creating a Plan of Care with a PRIORITY Lab: Lab: Normal Value: Why Relevant? Nursing Assessments/Interventions Required: 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 PRIORITY Setting: Which Orders Do You Implement First and Why? (Remember your ABCs!) 3. 4. Medication Dosage Calculation: Medication/Dose: Mechanism of Action: Volume/time frame to Safely Administer: Nursing Assessment/Considerations: Ondansetron 4 mg IV 4mg/2 mL vial Blocks effects of serotonin- therefore decreasing incidence for nausea IV Push: Volume every 15 sec? -May increase serum bilirubin, ALT/AST levels -Assess level of nausea and vomiting Give over at least 3o seconds or 2-5 min 2 -Monitor for serotonin syndrome and extrapyramidal effects mg/ml Collaborative Care: Nursing 3. What nursing priority (ies) will guide your plan of care? (if more than one, list in order of PRIORITY) Fluid status/circulation and GI/ ascites 4. What interventions will you initiate based on this priority? Nursing Interventions: Rationale: Expected Outcome: 10. 11. 5. What body system(s) will you most thoroughly assess based on the primary/priority concern? Lungs- respiratory, GI focused, and circulation- blood pressure, neurological status 6. What is the worst possible/most likely complication to anticipate? -Portal Hypertension -Hepatic encephalopathy -ARDS -DIC -Spontaneous bacterial peritonitis leading to sepsis 7. What nursing assessments will identify this complication EARLY if it develops? Bleeding- petechiae, gums, mucus membranes, from IV, in stools, in vomit Hepatic encephalopathy- labs, skin colors, ascites ARDS- labored rapid breathing, dry hacking cough Peritonitis- abdominal distention and tenderness/pain, ↑ WBC and temp What nursing interventions will you initiate if this complication develops? Stop any active bleeding Administer lactulose Recommend paracentesis and cultures if not already ordered Breathing treatment and oxygen supplementation 8. What psychosocial needs will this patient and/or family likely have that will need to be addressed? Support, education encouragement, caring, self-destructive behavior, possible treatment of depression and/or anxiety 8. How can the nurse address these psychosocial needs? Support the patient and the family by caring and implementing interventions timely. Refer to support groups/call social worker/case manager. Assess for depression and anxiety and treat or recommend counseling or medications. Educate on disease process and treatment. Evaluation: Six Months Later… John continues to drink ETOH on a daily basis and has not followed through with his discharge plan when he was discharged from the hospital six months ago. John is now homeless and lives in a shelter. He was brought into the ED by emergency medical services (EMS) because he was found wandering aimlessly in the neighborhood and was completely disoriented. The primary care provider in the ED orders the following labs: CBC, BMP, LFT, and INR. Current VS: Current PQRST: T: 99.5 F/37.5 C (oral) Provoking/Palliative: DENIES P: 118 (reg) Quality: R: 22 (reg) Region/Radiation: BP: 88/50 Severity: O2 sat: 94% room air Timing: Current Assessment: GENERAL APPEARANCE: Disheveled, clothing dirty, has strong body odor, appears unkempt, does not smell of ETOH RESP: Breath sounds clear with equal aeration bilaterally, non-labored respiratory effort CARDIAC: Jaundiced, warm & dry, no edema, heart sounds regular with no abnormal beats, pulses strong, equal with palpation at radial/pedal/post-tibial landmarks NEURO: Confused and disoriented to person, place, time, and situation (x4) GI: Abdomen protuberant–distended, bowel sounds audible per auscultation in all 4 quadrants GU: Voiding without difficulty, urine clear/orange SKIN: Skin integrity intact, skin is yellow/jaundiced in color with yellow sclera 1. What clinical data is RELEVANT that must be recognized as clinically significant? RELEVANT VS Data: Rationale: Temp PR BP Slightly elevated PR high- compensating for low BP? BP is low RELEVANT Assessment Data: Rationale: Unkept Jaundiced Not A+O Distended abdomen Orange urine and yellow skin Not taking care of himself Liver dysfunction- ↑ bilirubin Possible build up of ammonia Ascites ↑ Bilirubin – jaundice Compare & Contrast: Last Nursing Assessment 6 Months Ago: Emphasize that the nurse should look back at previous admissions, especially admission H&P, consultation H&P, discharge summary, and labs/diagnostics as time allows. Discharge summary may be most important if time is of the essence. An essential component of clinical reasoning is TRENDING clinical data. This TREND can be established from most recent documentation in the medical record that could be hours, days or even months ago. This data is still relevant and needed to establish this trend! Last Nursing Assessment 6 Months Ago: GENERAL APPEARANCE: Appears uncomfortable, restless RESP: Breath sounds clear with equal aeration bilaterally, non-labored respiratory effort CARDIAC: Pink, warm & dry, no edema, heart sounds regular–S1S2, pulses strong, equal with palpation at radial/pedal/post-tibial landmarks NEURO: Alert & oriented to person, place, time, and situation (x4) GI: Abdomen large–rounded–firm to touch, bowel sounds audible per auscultation in all 4 quadrants GU: Voiding without difficulty, urine clear/light orange SKIN: Skin integrity intact, color normal for patient, sclera of eyes light yellow in color, lips and oral mucosa tacky dry 2. Compare the current nursing assessment with his last assessment above. What has changed most dramatically from his last assessment six months ago that is clinically significant? Patient’s status is worsening- possible hepatic encephalopathy 3. Has his status improved or not as expected to this point? No improvement Lab Results: Complete Blood Count (CBC:) Current: High/Low/WNL? Previous: WBC (4.5–11.0 mm 3) 6.9 WNL 12.8 Hgb (12–16 g/dL) 8.9 LOW 10.2 Platelets (150-450 x103/µl) 47 LOW 98 Neutrophil % (42–72) 68 WNL 88 Band forms (3–5%) 3 HIGH 3 What lab results are RELEVANT that must be recognized as clinically significant to the nurse? RELEVANT Lab(s): Clinical Significance: TREND: Improve/Worsening/Stable: Hgb + platelets Bands Low- risk for bleeding Immature neutrophils Worsening Same Basic Metabolic Panel (BMP:) Current: High/Low/WNL? Previous: Sodium (135–145 mEq/L) 127 LOW 135 Potassium (3.5–5.0 mEq/L) 2.8 LOW 3.5 Glucose (70–110 mg/dL) 74 Low end of normal 78 BUN (7–25 mg/dl) 55 HIGH 38 Creatinine (0.6–1.2 mg/dL) 1.8 HIGH 1.5 RELEVANT Lab(s): Clinical Significance: TREND: Improve/Worsening/Stable: NA+ K+ BUN + Cr Low- dehydration/nutrition Low- dehydration/nutrition Kidneys not being perfused Worsening Worsening Coags: Current: High/Low/WNL? Previous: PT/INR (0.9–1.1 nmol/L) 2.6 HIGH- worsening 1.5 RELEVANT Lab(s): Clinical Significance: TREND: Improve/Worsening/Stable: PT/INR Bleeding risk Worsening Liver Function Test (LFT:) Current: High/Low/WNL? Previous: Albumin (3.5–5.5 g/dL) 2.2 LOW 2.5 Total Bilirubin (0.1–1.0 mg/dL) 7.2 HIGH 4.2 Alkaline Phosphatase male: 38–126 U/l female: 70–230 U/l 140 HIGH 285 ALT (8–20 U/L) 59 HIGH 128 AST (8–20 U/L) 62 HIGH 124 Misc. Labs: Ammonia (11–35 mcg/dL) 78 HIGH 30 RELEVANT Lab(s): Clinical Significance: TREND: Improve/Worsening/Stable: Albumin Bilirubin ALT/AST Ammonia LOW- nutrition/ fluid shifts HIGH: ammonia HIGH- liver damage Not being excreted Worsening Worsening Improved Worsening Lab Planning: Creating a Plan of Care with a PRIORITY Lab: Lab: Normal Value: Why Relevant? Nursing Assessments/Interventions Required: Ammonia Value: 78 Critical Value: Decreases A+O Toxins building up and not being excreted Assess A+O- maintain a safe environment Medical Management: Rationale for Treatment & Expected Outcomes Care Provider Orders: Rationale: Expected Outcome: Lactulose 200 g/300 mL rectal x1 NOW Banana bag (thiamine 100 mg-folic acid 1 mg- multivitamin 10 mL) in 1000 mL of 0.9% NS over 2 hours Potassium Chloride 10 mEq IVPB (x4) each dose over 1 hour. Recheck potassium per hospital protocol Transfer to ICU Bind and excrete ammonia Vitamin replacement- nutrition Potassium was low Appropriate- higher level of care Diarrhea ↓ ammonia Increased serum K+ 4. Does your nursing priority or plan of care need to be modified in any way after this evaluation and assessment of all clinical data including labs? 5. Based on your current evaluation, and assessment of all clinical data, what are your nursing priorities and plan of care? Priorities now- stabilize BP, hypokalemia, lactulose administration to excrete ammonia, maintain safe environment due to decreased LOC, bleeding precautions John is going to be admitted to ICU. Effective and concise handoffs are essential to excellent care and if not done well can adversely impact the care of this patient. You have done an excellent job to this point, now finish strong and give the following SBAR report to the nurse who will be caring for this patient: Situation: Name/age: BRIEF summary of primary problem: Day of admission/post-op #: Background: Primary problem/diagnosis: RELEVANT past medical history: RELEVANT background data: Assessment: Current vital signs: RELEVANT body system nursing assessment data: RELEVANT lab values: TREND of any abnormal clinical data (stable-increasing/decreasing): How have you advanced the plan of care? Patient response: INTERPRETATION of current clinical status (stable/unstable/worsening): Recommendation: Suggestions to advance plan of care: Education Priorities/Discharge Planning 1. What will be the most important discharge/education priorities you will reinforce with their medical condition to prevent future readmission with the same problem? Alcohol abstinence- let him know his condition can cause him to die Bring in case manager and social worker Caring and the “Art” of Nursing 1. What is the patient likely experiencing/feeling right now in this situation? Depression, hopelessness, low-self-esteem, not in control 2. What can you do to engage yourself with this patient’s experience, and show that he matters to you as a person? Don’t judge, listen, get them help and the appropriate care that they need, preform interventions timely Use Reflection to THINK Like a Nurse Reflection-IN-action (Tanner, 2006) is the nurse’s ability to accurately interpret the patient’s response to an intervention in the moment as the events are unfolding to make a correct clinical judgment. 1. What did I learn from this scenario? 2. How can I use what has been learned from this scenario to improve patient care in the future?