Cirrhosis
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 and worsening nausea and -Could be from the excessive drinking or malnutrition. Might be acute
vomiting the past three days pain.
- fatigued -From the nausea and vomiting (dehydration)
- poor appetite -He is drinking a lot and his BMI Is low, he probably isn’t eating enough
- binge drinking on most weekends -ASSESS (ask questions) perform a CAGE test
-BMI 17.6 -Normal BMI for an adult male should be 18.5-24.9
RELEVANT Data from Social History: Clinical Significance:
-Single, not married and lives alone -No support system to help
- Past heroin abuse (sober for 2 years) - Is he recovering well from the substance abuse? Does he need extra help
-Unemployed and has no health insurance -Does he need assistance with finding a job? Why is he jobless?
-Hep C -Pt does not have good follow up care
What is the RELATIONSHIP of your patient’s past medical history (PMH) and current meds?
Which medication treats which condition?) (Write the number of the medication that connects to PMH)
PMH: Home Meds: Pharm. Classification: Expected Outcome:
*Hepatitis C–past history of 1. Ibuprofen 600 mg Nonsteroidal anti- -After some research I saw
IV drug abuse PO prn for headache inflammatory drug that most pts take this med on
*ETOH abuse x 25 years (NSAIDs) Hep C however it was cause
Cirrhosis or hepatotoxicity
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?
Write the PMH problem that likely started FIRST.
Write 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:
-T- 100.5 F/38.1 C (oral) -Fever can be a sign of infection. Pt may have signs cirrhosis
-Pain is 6/10 in the RUQ -The type of pain he is feeling is described as an ache most likely continuous and pt
needs to be assessed. In the RUQ the liver is present in this area.
Standing HR: 132 -Elevated can be from over exertion on his body or dehydration
Current Assessment:
GENERAL Appears uncomfortable, body tense, occasional facial grimacing
APPEARANCE:
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:
-GA: Appears uncomfortable, body is tense -Patient is in pain, his pain is 6/10
and occasional grimace
-Cardiac- 1+ pitting edema in the lower -Fluid retention
extremities
-GI- distended, round and firm. Bowel -swollen abdomen can signify a liver malfunction and imbalance in his proteins
sounds audible in the body. Also a fluid buildup.
-GU- Pubic hair loss and light orange urine -Light orange urine can indicate a problem with liver or bile duct. Can make
urine concentrated. Loss of pubic hair can show an imbalance with hormones
-Sclera is light yellow -Jaundice
Lab Results:
Complete Blood Count (CBC:) Current: High/Low/WNL? Previous:
WBC (4.5–11.0 mm 3) 12.8 HIGH 9.5
Hgb (12–16 g/dL) 10.2 LOW 11.2
Platelets (150-450 x103/µl) 98 LOW 122
Neutrophil % (42–72) 88 HIGH 75
Band forms (3–5%) 3 NORMAL 0
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 and worsening nausea and -Could be from the excessive drinking or malnutrition. Might be acute
vomiting the past three days pain.
- fatigued -From the nausea and vomiting (dehydration)
- poor appetite -He is drinking a lot and his BMI Is low, he probably isn’t eating enough
- binge drinking on most weekends -ASSESS (ask questions) perform a CAGE test
-BMI 17.6 -Normal BMI for an adult male should be 18.5-24.9
RELEVANT Data from Social History: Clinical Significance:
-Single, not married and lives alone -No support system to help
- Past heroin abuse (sober for 2 years) - Is he recovering well from the substance abuse? Does he need extra help
-Unemployed and has no health insurance -Does he need assistance with finding a job? Why is he jobless?
-Hep C -Pt does not have good follow up care
What is the RELATIONSHIP of your patient’s past medical history (PMH) and current meds?
Which medication treats which condition?) (Write the number of the medication that connects to PMH)
PMH: Home Meds: Pharm. Classification: Expected Outcome:
*Hepatitis C–past history of 1. Ibuprofen 600 mg Nonsteroidal anti- -After some research I saw
IV drug abuse PO prn for headache inflammatory drug that most pts take this med on
*ETOH abuse x 25 years (NSAIDs) Hep C however it was cause
Cirrhosis or hepatotoxicity
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?
Write the PMH problem that likely started FIRST.
Write 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:
-T- 100.5 F/38.1 C (oral) -Fever can be a sign of infection. Pt may have signs cirrhosis
-Pain is 6/10 in the RUQ -The type of pain he is feeling is described as an ache most likely continuous and pt
needs to be assessed. In the RUQ the liver is present in this area.
Standing HR: 132 -Elevated can be from over exertion on his body or dehydration
Current Assessment:
GENERAL Appears uncomfortable, body tense, occasional facial grimacing
APPEARANCE:
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:
-GA: Appears uncomfortable, body is tense -Patient is in pain, his pain is 6/10
and occasional grimace
-Cardiac- 1+ pitting edema in the lower -Fluid retention
extremities
-GI- distended, round and firm. Bowel -swollen abdomen can signify a liver malfunction and imbalance in his proteins
sounds audible in the body. Also a fluid buildup.
-GU- Pubic hair loss and light orange urine -Light orange urine can indicate a problem with liver or bile duct. Can make
urine concentrated. Loss of pubic hair can show an imbalance with hormones
-Sclera is light yellow -Jaundice
Lab Results:
Complete Blood Count (CBC:) Current: High/Low/WNL? Previous:
WBC (4.5–11.0 mm 3) 12.8 HIGH 9.5
Hgb (12–16 g/dL) 10.2 LOW 11.2
Platelets (150-450 x103/µl) 98 LOW 122
Neutrophil % (42–72) 88 HIGH 75
Band forms (3–5%) 3 NORMAL 0
