Question

A 52-year-old male with a history of smoking and alcohol abuse. He presents to the ED with complaints of "my skin looks yellow, my stomach hurts, and I feel nauseous". He is taken to CT and a tumor near the pancreas is observed. It appears to be blocking the common bile duct

.please answer the questions below

Possible Medications (Minimum of 2 medications needed)

Clinical Manifestations Subjective: Objective:

Possible Nursing Diagnosis           (Minimum of 2 needed)

Medical Diagnosis Cirrhosis and Liver Cancer

Patient Data/Risk Factors

Medical Interventions

Pathophysiology

Nursing Interventions (Minimum of 4 needed)

Diagnostic Data (Minimum of 1 needed)

Patient Education

Answer 1

Ans) The end-stage of liver disease is called cirrhosis.

- Hepatic cirrhosis is a chronic hepatic disease characterized by diffuse destruction and fibrotic regeneration of hepatic cells.
- As necrotic tissue yields to fibrosis, this disease alters liver structure and normal vasculature, impairs blood and lymph flow, and ultimately causes hepatic insufficiency.
- The prognosis is better in noncirrhotic forms of hepatic fibrosis, which cause minimal hepatic dysfunction and don’t destroy liver cells.

- Clinical manifestations of the different types of cirrhosis are similar, regardless of the cause.

GI system. Early indicators usually involve gastrointestinal signs and symptoms such as anorexia, indigestion, nausea, vomiting constipation, or diarrhea.
Respiratory system. Respiratory symptoms occur late as a result of hepatic insufficiency and portal hypertension, such as pleural effusion and limited thoracic expansion due to abdominal ascites, interfering with efficient gas exchange leading to hypoxia.
Central nervous system. Signs of hepatic encephalopathy also occur as a late sign, and these are lethargy, mental changes, slurred speech, asterixis (flapping tremor), peripheral neuritis, paranoia, hallucinations, extreme obtundation, and ultimately, coma.
Hematologic.The patient experiences bleeding tendencies and anemia.
Endocrine. The male patient experiences testicular atrophies, while the female patient may have menstrual irregularities, and gynecomastia and loss of chest and axillary hair.
Skin. There is severe pruritus, extreme dryness, poor tissue turgor, abnormal pigmentation, spider angiomas, palmar erythema, and possibly jaundice.
Hepatic. Cirrhosis causes jaundice, ascites, hepatomegaly, edema of the legs, hepatic encephalopathy, and hepatic renal syndrome.

- Complications:
The complications of hepatic cirrhosis include the following:

• Portal hypertension- Portal hypertension is the elevation of pressure in the portal vein that occurs when blood flow meets increased resistance.
• Esophageal varices- Esophageal varices are dilated tortuous veins in submucosa of the lower esophagus.
• Hepatic encephalopathy may manifest as deteriorating mental status and dementia or as physical signs such as abnormal involuntary and voluntary movements.
• Fluid volume excess- Fluid volume excess occurs due to an increased cardiac output and decreased peripheral vascular resistance.

- Pathophysiology:
Although several factors have been implicated in the etiology of cirrhosis, alcohol consumption is considered the major causative factor.

Necrosis. Cirrhosis is characterized by episodes of necrosis involving the liver cells.
Scar tissue. The destroyed liver cells are gradually replaced with a scar tissue.
Fibrosis. There is diffuse destruction and fibrotic regeneration of hepatic cells.
Alteration. As necrotic tissue yields to fibrosis, the disease alters the liver structure and normal vasculature, impairs blood and lymph flow, and ultimately causes hepatic insufficiency.

Medical Management:
Treatment is designed to remove or alleviate the underlying cause of cirrhosis.

Diet. The patient may benefit from a high-calorie and a medium to high protein diet, as developing hepatic encephalopathy mandates restricted protein intake.
Sodium restriction.is usually restricted to 2g/day.
Fluid restriction. Fluids are restricted to 1 to 1.5 liters/day.
Activity. Rest and moderate exercise is essential.
Paracentesis. Paracentesis may help alleviate ascites.
Sengstaken-Blakemore or Minnesota tube. The Sengstaken-Blakemore or Minnesota tube may also help control hemorrhage by applying pressure on the bleeding site.

- Pharmacologic Therapy
Drug therapy requires special caution because the cirrhotic liver cannot detoxify harmful agents effectively.

Octreotide. If required, octreotide may be prescribed for esophageal varices.
Diuretics. Diuretics may be given for edema, however, they require careful monitoring because fluid and electrolyte imbalance may precipitate hepatic encephalopathy.
Lactulose. Encephalopathy is treated with lactulose.
Antibiotics. Antibiotics are used to decrease intestinal bacteria and reduce ammonia production, one of the causes of encephalopathy.
Surgical Management
Surgical procedures for management of hepatic cirrhosis include:

Transjugular intrahepatic portosystemic shunt (TIPS) procedure. The TIPS procedure is used for the treatment of varices by upper endoscopy with banding to relieve portal hypertension.

- Nursing Management:
Nursing management for the patient with cirrhosis of the liver should focus on promoting rest, improving nutritional status, providing skin care, reducing risk of injury, and monitoring and managing complications.

Nursing Assessment:
Assessment of the patient with cirrhosis should include assessing for:

Bleeding. Check the patient’s skin, gums, stools, and vomitus for bleeding.
Fluid retention. To assess for fluid retention, weigh the patient and measure abdominal girth at least once daily.
Mentation. Assess the patient’s level of consciousness often and observe closely for changes in behavior or personality.

Nursing Diagnosis:
Based on the assessment data, the major nursing diagnosis for the patient are:

Activity intolerance related to fatigue, lethargy, and malaise.
Imbalanced nutrition: less than body requirements related to abdominal distention and discomfort and anorexia.
Impaired skin integrity related to pruritus from jaundice and edema.
High risk for injury related to altered clotting mechanisms and altered level of consciousness.
Disturbed body image related to changes in appearance, sexual dysfunction, and role function.
Chronic pain and discomfort related to enlarged liver and ascites.
Fluid volume excess related ascites and edema formation.
Disturbed thought processes and potential for mental deterioration related to abnormal liver function and increased serum ammonia level.
Ineffective breathing pattern related to ascites and restriction of thoracic excursion secondary to ascites, abdominal distention, and fluid in the thoracic cavity.

Nursing Care Planning & Goals:

The major goals for a patient with cirrhosis are:

Report decrease in fatigue and increased ability to participate in activities.
Maintain a positive nitrogen balance, no further loss of muscle mass, and meet nutritional requirements.

Nursing Interventions:

•Promoting Rest:

Position bed for maximal respiratory efficiency; provide oxygen if needed.
Initiate efforts to prevent respiratory, circulatory, and vascular disturbances.
Encourage patient to increase activity gradually and plan rest with activity and mild exercise.

•Improving Nutritional Status:

Provide a nutritious, high-protein diet supplemented by B-complex vitamins and others, including A, C, and K.
Encourage patient to eat: Provide small, frequent meals, consider patient preferences, and provide protein supplements, if indicated.
Provide nutrients by feeding tube or total PN if needed.
Provide patients who have fatty stools (steatorrhea) with water-soluble forms of fat-soluble vitamins A, D, and E, and give folic acid and iron to prevent anemia.
Provide a low-protein diet temporarily if patient shows signs of impending or advancing coma; restrict sodium if needed.

•Providing Skin Care:

Change patient’s position frequently.
Avoid using irritating soaps and adhesive tape.
Provide lotion to soothe irritated skin; take measures to prevent patient from scratching the skin.

•Reducing Risk of Injury:

Use padded side rails if patient becomes agitated or restless.
Orient to time, place, and procedures to minimize agitation.
Instruct patient to ask for assistance to get out of bed.
Carefully evaluate any injury because of the possibility of internal bleeding.
Provide safety measures to prevent injury or cuts (electric razor, soft toothbrush).
Apply pressure to venipuncture sites to minimize bleeding.

Monitoring and Managing Complications:

Monitor for bleeding and hemorrhage.
Monitor the patient’s mental status closely and report changes so that treatment of encephalopathy can be initiated promptly.
Carefully monitor serum electrolyte levels are and correct if abnormal.
Administer oxygen if oxygen desaturation occurs; monitor for fever or abdominal pain, which may signal the onset of bacterial peritonitis or other infection.
Assess cardiovascular and respiratory status; administer diuretics, implement fluid restrictions, and enhance patient positioning, if needed.
Monitor intake and output, daily weight changes, changes in abdominal girth, and edema formation.
Monitor for nocturia and, later, for oliguria, because these states indicate increasing severity of liver dysfunction.

Patient Education:

- The focus of discharge education is dietary instructions.

Alcohol restriction- Of greatest importance is the exclusion of alcohol from the diet, so the patient may need referral to Alcoholics Anonymous, psychiatric care, or counseling.
Sodium restriction- Sodium restriction will continue for considerable time, if not permanently.
Complication education- The nurse also instructs the patient and family about symptoms of impending encephalopathy, possible bleeding tendencies, and susceptibility to infection.