Question

Client Profile

Mr. Escobar is a 47-year old male with a history of cirrhosis. He lives with his wife and teenage sons. His wife brought him to the emergency department today because she noticed that Mr. Escobar had increasing confusion and lethargy and was having difficulty walking. His wife states, ?He is probably acting a little funny because he is sleep deprived. He hasn?t slept very much in the past few days.

Case Study

Mr. Escobar is afebrile. His blood pressure is 136/68, pulse 88, and respiratory rate 18. His oxygen saturation is 98% on room air. He is awake, alert, and oriented to person only. His speech is slow and he appears tired. The nurse notices a foul odor to his breath. Upon physical examination, Mr. Escobar has a slightly distended abdomen. The health care provider (HCP) does not note any asterixis. The HCP requests an abdominal ultrasound, which reveals fatty infiltration of the liver, an enlarged spleen, a polyp in his gallbladder, and a moderate amount of ascites. Results of the complete blood count (CBC) reveal white blood count (WBC) 4.8 cells/mm³, red blood cell count (RBC) 2.94 million/mm³, hemoglobin (Hgb) 9.8 g/dL, hematocrit (Hct) 28.2%, and platelet count 89,000 mm³. Results of a comprehensive metabolic panel (CMP) are sodium 145 mEq/dL and creatinine1.6 mg/dL. Liver function test (LFTs) reveal total protein 5.7/dL, albumin 3.1 g/dL, total bilirubin 1.8 mg/dL, aspartate aminotransferase (AST) 17 U/L, alanine aminotransferase (ALT) 14 U/L, and lactace

(AST) 17 U/L, alanine aminotransferase (ALT) 14 U/L, and lactace dehydrogenase (LDH, LD) of 266 U/L. His prothrombin time is 13.1 seconds. His ammonia level is 124 umol/L. Urinalysis results are within normal limits. The HCP schedules Mr. Escobar for a gastroscopy to rule out any gastrointestinal (GI) bleeding. Intravenous (IV) fluids include D5^1/2 NS are started at 100 mL per hour.   Medications prescribes include lactulose and neomycin sulfate. The HCP admitting Mr. Escobar also prescribes daily weights, strict intake and output documentation, monitoring of stools for occult blood, neurological assessment every four hours, and a low-protein low-sodium diet.

Questions

1. Mr. Escobar has cirrhosis. Briefly discuss the pathophysiology of this disease and its incidence in the United States.
2. Briefly explain how hepatic encephalopathy is related to cirrhosis.
3. Upon initial examination, the HCP did not note any asterixis. What is asterixis, and how did the HCP assess Mr. Escobar for this condition?
4. Identify the characteristic clinical manifestations of hepatic encephalopathy consistent with Mr. Escobar?s presentation.
5. Identify three priority nursing diagnoses for Mr. Escobar. NO ?AT RISK FOR? DIAGNOSES
6. Identify which of the client?s admitting laboratory results are abnormal and provide a rationale for why each is above or below the normal range.
7. Define ascites. Explain what causes ascites and how the nurse will assess for this condition.
8. Mr. Escobar has been prescribed 30 mL of lactulose every six hours and neomycin sulfate, 500 mg four times a day. Explain wh7 each of these medications has been included in the client?s medical management plan. What should the nurse teach Mr. Escobar regarding the potential adverse effects of each medication.
9. When should the nurse anticipate the onset of the effects of lactulose? Describe the therapeutic effects of lactulose on Mr. Escobar?s bowel pattern. While evaluating the effectiveness of the lactulose, what finding would indicate a potential lactulose overdose?
10. Provide a brief rationale for the low-protein, low-sodium diet the HCP prescribed for Mr. Escobar.
11. A gastroscopy reveals that Mr. Escobar has esophageal varices, which are treated with banding. Briefly discuss what esophageal varices are and banding procedure used to treat them.
12. Briefly explain how Mr. Escobar?s hepatic encephalopathy is related to the esophageal varices.
13. Mr. Escobar is being discharged, and the nurse is educating the client about minimizing his risk for further injury. Provide a list of at least three precautions to decrease his risk of hemorrhage from future esophageal varices.

Answer 1

1.Pathophysiology of Cirrhosis

Cirrhosis of liver is the fibrosis of liver which occurs at the last stage due to many disease conditions of liver.

Pathophysiology: Liver plays an important role in protein synthesis, detoxification, and storage and also helps in metabolism of lipids and carbohydrates.

Cirrhosis is caused by hepatitis or fatty liver. Development of Scar tissue replaces the normal parenchyma. This blocks the normal blood flow and increases the pressure disturbing the normal function.Damage to the hepatic parenchyma due to inflamation lrasd to activation of the Stellete cells which increases the fibrosis. As this progresses, fibrous tissue bands separates the hepatocyte nodulesevetually replacing the entire liver textureleadin to decreased blood flow throughout. This increases the portal hypertension which increases the complication of cirrhosis.

Prevelence of Cirrhosis in US:   Approximately 0.27%in US has cirrhosis of liver.That is around 633,000 adults are nearly suffering from this disease as per the research studies.

2.Hepatic Encephalopathy is a disorder caused by the buildup of toxins which can happen with advanced liver disease.This can effect the mood, behaviour, speech, sleep. . Hepatic encephalopathy starts when the liver gets damaged from a long term disease like Chronic hepatitis, Reye's disease, Cirrhosis. The toxins travel into the blood stream and reaches the brain . This inturn causes mental and physical symptoms.

3.Asterixis: This is defined as the tremors of hands when the wrist is extendedSometimes resembling a bird flapping its wings.This motor disodrer is an inability to maintain a position which is demonstrated by jery movements.This is usually caused by the abnormal function of the Diencephalic motor centres of the brain.

In the above case the HCP did not perform a complete physical examination hence was unable to note Asterixis. He only noted for distended abdomen. Asterixis can be elicited by physical examination . The patient extends the arms, dorsiflex the wrists and spreads the fingers with eyes closed.This is used to test flap at the wrist and is the common method of assessment to elicit asterixis.

4. Clinical manifestation: Hepatic encephalopathy is characterised by personality changes , intellectual impairment, depressed level of conciousness. The symptoms incude:

• Confusion
• Disorientation
• Reduced conciousness
• Lethargy
• Personality changes
• confused speech
• Shaky hands
• Slow movements
• Poor concentration

In the above case Mr Escobar has the following symptoms:

• Increased confusion and lethargy
• Difficulty walking
• Foul odor in the breath
• Distended abdomen
• Sleep deprived

All these symptoms which Mr Escobar has shows that he can probably have hepatic encephalopathy as he also has a history of cirrhosis.

5.Nursing diagnosis

• Imbalance nutrition less than body requirement : Here the patient is on Diet restrictions like low protein low salt diet.
• Deficient fluid volume related to decreased intake and ascitis as evidenced by examination.
• Ineffective breathing pattern related to hypoxia

6.