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