Question

Case Studies unit 3 Hepatobiliary

1. John Adams, 55 years of age, is admitted to the intensive care unit with the diagnosis of acute esophageal varices bleed. The patient has a long-standing history of alcoholism and cirrhosis of the liver. Six months ago, the patient received an EGD, which diagnosed the esophageal varices. The patient has quit drinking alcohol for the past 6 months and has been active in Alcoholics Anonymous. The patient has a history of coronary artery disease and angina. The patient has been taking nadolol (Corgard) and isosorbide (Isordil). The admission vital signs include: BP, 88/50; P, 110; R, 26; and T, 99°F. The supplemental oxygen is on room air and the patient is placed on 2 L/min of oxygen per nasal cannula with supplemental oxygen. The patient’s hemoglobin is 6 g/dL, the hematocrit is 12%, and the platelets are 75,000. The patient has a prolonged PT and PTT. The liver profile shows a mild elevation of the aspartate aminotransferase (AST) and the alanine aminotransferase (ALT). The BUN and serum creatinine are also elevated. The patient has in place from the emergency department a nasogastric tube to low wall suction. The emergency department physician placed a right subclavian triple lumen catheter and there is NS infusing at 100 mL/hr. The emergency department nurse administered vitamin K. Additional orders on the chart from the gastroenterologist include the following: octreotide (Sandostatin) 5-mcg bolus followed with continuous infusion 500 mcg in 250 mL D₅NS at 25 mcg/hr. Type and cross of 6 units of PRBCs STAT and transfuse 2 units of PRBCs over 2 hours each and administer furosemide (Lasix) 20 mg IVP in between each unit. Repeat CBC 1 hour after the transfusion is completed.

a. List the patient’s abnormal lab test results, normal values of the same labs, and provide a rationale for these abnormalities.

Mr. Adam’s condition has stabilized, and he has been transferred to a medical floor.

1. Describe physical assessment techniques used to assess patients with liver disease.

2. The nurse is preparing the patient for discharge. Outline a teaching plan about self-care.

2. Answer the following questions:

1. The nurse implementing a care plan for a patient with liver disease, knows that the priority nursing action is…

1. Implement bleeding precautions

2. Provide a high carbohydrate diet

3. Refer to a support group

4. Monitor lab values

    

Answer 1

A. patients abnormal values as follows:

• hemoglobin patient value is 6 g/dL, normal value for Male: 13.8 to 17.2g/dl. Hb reduction is due to esophageal varices bleed.
• hematocrit is 12% normal value For men, 38.3 to 48.6 %, Hct value also reduced due to compensation of fluid loss by the plasma volume.here the RBCs are lost and cannot be replaced.
• platelets are 75,000 normal value ranges between 150,000 to 350,000. the alcohol may reduce the platelet volume.
• ALT patient value is >55U/L normal value ranges between 7 - 55U/L, the rate increased due to alcholic liver cirrhosis because of B depletion and mitochondrial damage. liver damage causes slight elevation of enzymes.
• AST patient value is >48 U/L normal value ranges between 8 - 48U/L the rate is increased due to alcholic liver cirrhosis because of B depletion and mitochondrial damage. liver damage causes slight elevation of enzymes.
• BUN, patient value is >20mg/dl normal value ranges between 7 -20mg/dl; creatine, patient value is > 1.2 mg dl normal value ranges between 0.8 - 1.2mg/dl. The BUN & creatine increased related to alteration in kidney perfusion due to splanchnic vasodilation associated with portal hypertension.

PHYSICAL EXAMINATION (liver cirrhosis):

INSPECTION:

• appearance- weak, skin - yellow discoloration, pallor, palmar erythema, spider angioma, etc..
• on abdomen: abdominal distension, caput medusae
• Atrexis willl be present in hands., edema, nail changes, clubbing etc..

PALPATION:

• fluid wave,
• hepatomegaly
• spleenomegaly

PERCUSSION:

• flank dullness

AUSCULTATION:

• Cruveilhier-Baumgarten murmer

DISCHARGE TEACHING PLAN:

• Avoid alcohol
• do not limit the protein intake
• check the weight daily, any sudden change form the doctor.
• limit canned, packaged and fast foods.
• salt restriction
• take the medicines exactly as directedd.
• proper follow-upcare

Priority nusing action as follows:

Provide a high carbohydrate diet