Our Lady of Fatima University

120 McArthur Highway, Valenzuela City, Philippines

Bachelor of Science in Nursing

CASE STUDY:
LIVER CIRRHOSIS

In partial fulfillment of the requirements for

Medical Ward- Related Experience

Quezon City General Hospital

Submitted By:
BSN 3-3A&3B

Alday, Athena Kim N.

Celestino, Kurt Justin P.
Abaño, Mary Rei Ann N.
Abenir, John Royce P.
Antiporta, Cyrell S.
Bartolome, Christine Reyl B.
Bon, Christine G.
Cuevas, Cheezalyn T.
Daclison, Rudolf V.

Submitted to:
Mrs. Almira Catiis Gabriel

March 2023
I. INTRODUCTION

a. Patient Profile
Name: C.A
Sex: Male
Age: 53 years old
Marital Status: Married
Weight: 108 kg
Height: 165 cm

b. Medical History

Admission Diagnosis: Cirrhosis of Liver

Chief Complaint: Abdominal distention, moderate shortness of breathing, +2 edema on both feet

History of Present Illness

Patient C.A, a 56 years old male was taken into the emergency department due to a complaint of abdominal
distention which started two days ago. Patient reported having a beer belly for about ten years that has
become larger over the previous month and is now becoming quite tender during the last three days. In
addition, the patient reported having had dark-colored feces for a week as well as loss of appetite, confusion,
and swelling in both legs over the previous three days. There was no recently reported infection.

Past Medical History:

2015- Diagnosed with hypertension and began on unknown medication. Stopped after 6 months because of
drowsiness.

c. Psychosocial
● Drinks 6-8 cans of beer/day and more on weekends for approximately 18 years already, had his
last beer 2 days ago
● + Smoking

d. Physical Examination

T: 36.5 °C
PR: 120, regular
RR: 24, slightly labored
BP: 140/80

● Slight scleral icterus and mild jaundice on the skin

● Spider angiomas on upper chest and abdomen
● Several bruises on the lower extremities
● Rapid, shallow breathing pattern
 ● Large and distended abdomen
● Positive fluid wave; difficult to ascertain liver border
● +2 edema of both feet

II. LABORATORY

TESTS RESULT NORMAL EXPLANATION

VALUES

ALT is an enzyme produced by

ALT (Alanine Increased 10-40 U/L liver cells. Elevated levels of
aminotransferase) ALT in the blood can indicate
liver damage or inflammation.

ALT (Alanine AST is another enzyme

aminotransferase) Increased 10-30 U/L produced by liver cells.
Elevated levels of AST can
indicate liver damage or
inflammation.

Bilirubin is a waste product

produced by the liver. Elevated
levels of bilirubin in the blood
Total Bilirubin Increased 0.2-1.2 mg/dL can indicate liver damage or
dysfunction and can also cause
jaundice (yellowing of the skin
and eyes).

Serum ammonia levels can be

elevated in liver cirrhosis due
Serum Ammonia Increased 15-45 mcg N/dL to the impaired ability of the
damaged liver to convert
ammonia into urea, leading to
a buildup of ammonia in the
blood. This increased ammonia
can then cause neurological
symptoms and contribute to the
development of hepatic
 encephalopathy.

Serum albumin levels are

typically decreased in liver
Albumin Decreased 3.5-5.2 g/dL cirrhosis due to the impaired
ability of the damaged liver to
produce and secrete albumin
into the bloodstream. As the
liver function declines, the
production of albumin
decreases, resulting in lower
levels in the blood.

PT 9.4-12.5 seconds PT (prothrombin time), PTT

Prolonged (partial thromboplastin time),
and INR (international
normalized ratio) can be
prolonged. This is due to the
liver's impaired ability to
PTT 25-37 seconds produce clotting factors, which
are essential for blood
coagulation. As a result, these
tests can be used to assess liver
function and diagnose liver
cirrhosis, with higher values
INR 0.9-1.1 indicating a higher risk of
bleeding.

Platelet count is typically

decreased in liver cirrhosis due
Platelets Decreased 150,000-400,00 to the reduced production of
microliter thrombopoietin, a hormone
that stimulates platelet
production, by the damaged
liver.
III. REVIEW OF ANATOMY AND PHYSIOLOGY

ANATOMY

The liver, the biggest internal organ of the

body, is a reddish-brown, rubbery-feeling
organ that is situated in the right upper
quadrant (RUQ) of the abdominal cavity.
The liver has a typical form resembling a
prism or wedge. Except for the region that
meets the inferior surface of the
diaphragm at the top, which is also known
as the naked area, it is covered by the
visceral peritoneum. In a healthy person,
it should weigh around 3 pounds and be
completely covered by the rib cage,
making it impossible to palpate.

Right, left, caudate, and quadrate are the four lobes that make up the liver. On the inferior surface of the right
lobe is where the quadrate lobe is located. At a superior and anterior position, the caudate lobe is situated
between the left and right lobes.

PHYSIOLOGY

As a component of the digestive system, the liver works closely with

the pancreas, the intestines, and the gallbladder, which is positioned
underneath the liver, to digest, absorb, and process food. Before it is
sent to the rest of the body, the liver's primary function is to filter blood
arriving from the digestive system. In addition to receiving absorbed
nutrients, it also detoxifies ingested toxic compounds like narcotics. It
functions as an endocrine and exocrine organ. The primary exocrine
functions of the liver include bile salt production and excretion into the
common hepatic duct, as well as bilirubin conjugation and excretion
into the intestine. Involvement in glycemic regulation via insulin and
glucagon is one of the liver's endocrine roles. In addition to
synthesizing vital proteins including albumin, prothrombin,
fibrinogen, and other amino acids, the liver also transforms proteins
into enzymes and peptide hormones.
The liver produces cholesterol, phospholipids, and lipoproteins in
addition to taking role in the metabolism of fatty acids. It also participates in the metabolism of carbohydrates,
including the gluconeogenic process and glycogen storage. Moreover, it participates in the metabolism of
lactic acid and turns ammonia into urea. Vitamins and minerals like iron are stored in the liver. In conclusion,
the liver is a key mediator between the gut and blood and is essential for the metabolism of macronutrients,
hormones, blood plasma components, and exocrine and endocrine chemicals
 IV. PATHOPHYSIOLOGY

V. DRUG STUDY

Name of Drug Indication Action Contraindication Adverse/Side Nursing

Effect Responsibilities

GENERIC Retinal function Stimulates the Taking high doses ● Bone Evaluate dosage
NAME: that is used production and of vitamin A thinning. with consideration
Vitamin A clinically to activity of white supplements can ● Liver of patient's
correct vitamin blood cells, cause liver damage. average daily
BRAND NAME: A deficiency. takes part in damage. ● Headache. intake of vitamin
Retinol, Aquasol A remodeling Combining high ● Diarrhea. A
bone, helps doses of vitamin ● Nausea.
CLASSIFICATIO maintain A supplements ● Skin Take dietary and
N: healthy with other drugs irritation. drug history
fat-soluble vitamin endothelial cells that can damage ● Pain in the
and regulates the liver could joints and Monitor
cell growth increase the risk bone. therapeutic
of liver disease ● Birth defects. effectiveness

GENERIC used to prevent Water-soluble Vitamin C is ● Nausea,

NAME: or treat low vitamin contraindicated in vomiting and ● Lab tests:
Vitamin C vitamin C levels essential for blood disorders diarrhea. Periodic Hct &
in people who do
synthesis and like thalassemia, ● Heartburn. Hgb, serum
BRAND NAME:
not get enough
maintenance of G6PD deficiency, ● Stomach electrolytes.
Ascorbic Acid collagen and sickle cell disease, cramps or ● Monitor for
of the vitamin intercellular and S&S of acute
bloating.
CLASSIFICATIO through their ground hemochromatosis. ● Fatigue and hemolytic
N: diet substance of sleepiness, or anemia, sickle
antioxidants body tissue sometimes cell crisis.
cells, blood insomnia.
vessels, ● Headache.
cartilage, bones, ● Skin
teeth, skin, and flushing.
tendons. Unlike
most mammals,
humans are
unable to
synthesize
ascorbic acid in
the body;
therefore it
must be
consumed daily.

GENERIC Manage and Helps to make Contraindicated in ● Decreased Educate the

NAME: treat bleeding various proteins phytonadione appetite. patient about the
Vitamin K due to the that are needed hypersensitivity, ● decreased indication and
for blood hereditary movement or contraindication of
coagulation
BRAND NAME: clotting and the hypoprothrombine activity. vitamin k
disorder caused
phytonadione building of mia, heparin over- ● difficulty in
by warfarin and bones anticoagulation Inform the patient
breathing.
CLASSIFICATIO vitamin K ● enlarged liver. about the side and
N: deficiency. ● general body adverse effect
fat-soluble vitamin swelling.
class of drugs Stop
● muscle
administration of
stiffness.
vitamin k if severe
● paleness. side effect occur
● yellow eyes or
skin. Instruct patient not
to take any
medication
without doctors
prescription

GENERIC Treatment of Helps keep the Vitamin E is ● Nausea. Assess dietary

NAME: vitamin E immune system contraindicated in ● Diarrhea. intake of vitamin e
Vitamin E deficiency which strong against persons with ● Intestinal
viruses and known allergies to cramps. When you notice
can occur in
BRAND NAME: bacteria. the vitamin or ● Fatigue. bleeding, it could
Aquasol E, alpha- cystic fibrosis, components of the ● Weakness. be drug reaction
tocopherol, and cholestasis and formulation. ● Headache. and it should be
tocopherol. severe liver ● Blurred discontinued
disease, vision.
CLASSIFICATIO abetalipoprotein ● Rash. Explain to the
N: emia or simply patient about the
antioxidants poor diet adverse and side
effects.

When you notice

any drug reaction,
inform the
physician
immediately.

GENERIC Edema Enhances Hypersensitivity ● Profound ● Assess vital

NAME: associated secretion of Na, to water loss or signs (hold if
furosemide with HF and Chloride, & K furosemide With
electrolyte
by direct action ● Anuria hypotension),
renal/hepatic depletion
BRAND NAME: at ascending I & O, serum
Lasix disease. limb of loop of resulting in electrolytes
● Acute Henle hypokalemia, (Na, K).
CLASSIFICATIO pulmonary
hyponatremia ● Provide
N: edema health
loop diuretics , and teaching
● Hypertension
dehydration. about:
● Sudden I. Monitoring I
volume &O
II. Signs of
restriction electrolyte
resulting to: imbalance
thrombosis, and report it
sudden III. Report
hearing
death, abnormalities
circulatory IV. Avoid
prolapsed. sunlight
● Episodes of V. Eat foods
high in K
acute
(whole
hypotensive grains,
at several banana,
days of taking raisins)
the
medication
● Ototoxicity
(Deafness,
tinnitus,
vertigo)
● Can
exacerbate
 diabetes
mellitus,
gout,
pancreatitis,
and systemic
lupus
erythematosus

GENERIC For the treatment Irreversibly Disulfiram is ● Drowsiness Do not administer

NAME: and management inhibits contraindicated ● Tiredness until patient has
Disulfiram of chronic aldehyde absolutely in ● Headache abstained from
dehydrogenase patients with ● acne, and alcohol for at least
alcoholism
BRAND NAME: (ALDH1A1) by significant ● metallic/garlic 12 hr
Antabuse competing with coronary artery like taste in
nicotinamide disease or heart the mouth Administer orally;
CLASSIFICATIO adenine failure. Cases of tablets may be
N: dinucleotide heart failure and crushed and mixed
alcohol antagonist (NAD) at the death have with liquid
cysteine residue occurred in beverages.
in the active site patients with
of the enzyme severe myocardial To assess hepatic
disease shortly impairment,
after the initiation perform liver
of disulfiram. function tests
before, after 10-14
days, and every 6
months during
therapy.

Explain to the
patient about the
adverse and side
effects.

When you notice

any drug reaction,
inform the
physician
immediately.
GENERIC aminoglycoside Decreases Oral neomycin is ● Any loss of Keep an eye out
NAME: antibiotic agent ammonia- contraindicated in hearing. for signs of
Neomycin used orally and producing patients with ● Clumsiness. hypersensitivity,
bacteria intestinal ● difficulty in such as pulmonary
topically to treat
BRAND NAME: obstruction and breathing. symptoms -
Neosporin Plus Pain a wide variety of those who have a ● greatly tightness in the
Relief Ointment and infections in the history of decreased throat
TriBioene body. hypersensitivity. frequency of -chest
Ointment. urination or -wheezing
Because of the amount of -cough
CLASSIFICATIO possibility of urine. -dyspnea
N: increased ● increased
aminoglycoside gastrointestinal amount of or skin reactions
antibiotics absorption, gas. -rash
neomycin is also ● increased -pruritus -urticaria.
contraindicated in thirst. If any of these
patients with ● light-colored, reactions occur,
inflammatory or frothy, fatty- notify your doctor
ulcerative appearing or nursing staff
gastrointestinal stools. right away.
disease. ● ringing or
buzzing or a
feeling of
fullness in the
ears.

GENERIC A lactose The mechanism In patients who ● Confusion. Explain to the

NAME: disaccharide of action is to require a low ● decreased patient the purpose
Lactulose derivative used reduce intestinal galactose diet, this urine. of lactulose.
ammonia medication is ● fast or Instruct the patient
to treat
BRAND NAME: production and contraindicated. irregular to take lactulose
Enulose, Kristalose, constipation and absorption. gastrointestinal heartbeat. exactly as
Constulose, and portal systemic obstruction and ● increased directed.
Generlac. encephalopathy. galactosemia thirst.
● lightheadedne Encourage
CLASSIFICATIO ss. patients to use
N: ● mood other forms of
Osmotically-Acting changes. bowel regulation,
Laxatives ● muscle pain, such as increasing
cramps, or dietary bulk, fluid
twitching. intake, and
● nausea or mobility.
vomiting.
Patients should be
informed that this
medication may
cause belching,
flatulence, or
abdominal
cramping. If this
 becomes
bothersome or if
diarrhea occurs,
contact a medical
professional

Inform the patient

that if a pregnancy
is planned or
suspected, or if
she is
breastfeeding, she
should notify a
healthcare
professional.

VI. NURSING CARE PLAN

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

VII. MEDICAL AND NURSING MANAGEMENT

Patient with Liver Cirrhosis, the medical managements are the following:

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.

Paracentesis: Paracentesis may help alleviate ascites.

Patient with liver cirrhosis, the nursing managements are the following:

Promoting Rest

● Position bed for maximal respiratory efficiency; provide oxygen if needed.

● Initiate efforts to prevent respiratory, circulatory, and vascular disturbances.
● Encourage patients 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 patients 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 the patient shows signs of impending or advancing coma;
restrict sodium if needed.

Providing Skin Care

● Change the patient's position frequently.

● Avoid using irritating soaps and adhesive tape.
● Provide lotion to soothe irritated skin; take measures to prevent patients from scratching the skin.

Reducing Risk of Injury

● Use padded side rails if the patient becomes agitated or restless.

● Orient to time, place, and procedures to minimize agitation.
● Instruct the 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 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.

VIII. DISCHARGE PLANNING

Planning for a patient's discharge from the hospital with liver cirrhosis will be influenced by the
condition's severity, its underlying etiology, and the patient's general health. A patient with liver cirrhosis
may have the following broad considerations in their discharge plan:

1. Medications: The patient may be prescribed medications to manage symptoms and complications
of cirrhosis, such as diuretics to reduce fluid buildup, lactulose to manage hepatic
encephalopathy, and medications to control blood pressure and prevent bleeding.
2. Diet: The patient may need to follow a specific diet to reduce the workload on the liver and
prevent further damage. This may include reducing salt intake and avoiding alcohol.
3. Follow-up appointments: The patient will need to follow-up with their healthcare provider
regularly to monitor their condition and ensure that the cirrhosis is managed effectively.
4. Home care: The patient may need assistance with activities of daily living, such as bathing or
dressing, until they fully recover.
5. Education: The patient and their family members should receive education on the signs and
symptoms of cirrhosis, how to manage symptoms, and when to seek medical attention.
6. Substance abuse treatment: If the cirrhosis is caused by alcohol or drug abuse, the patient may
need to seek substance abuse treatment to prevent further damage to the liver.
7. Vaccinations: The patient may need to receive vaccinations for hepatitis A and B to prevent
further liver damage.
8. Support services: The patient may benefit from support services, such as counseling or support
groups, to manage the emotional and psychological aspects of living with liver cirrhosis.

It's vital to understand that discharge planning for patients with liver cirrhosis will be unique to their
needs and may change depending on their circumstance. A thorough and individualized discharge plan
will be created for the patient in close collaboration with their healthcare practitioner, family, and other
stakeholders.
IX. EVALUATION

● Evaluate the patient's response to treatment, including improvement in symptoms, laboratory

values, and imaging studies.
● Monitor for complications and manage them promptly.
● Evaluate the patient's compliance with the treatment plan and educate them on self-care measures
to prevent complications and promote liver health.
● Collaborate with other healthcare providers, such as a hepatologist, gastroenterologist, or
transplant team, to ensure optimal care for the patient with liver cirrhosis.

X. RECOMMENDATIONS

● Avoid drinking alcohol

If a patient has cirrhosis caused by alcohol abuse, it is essential to stop drinking alcohol
completely to prevent further damage to the liver. Seek help from a medical professional or
support group if assistance with quitting is needed.

● Manage underlying conditions

If a patient has cirrhosis due to a chronic liver disease such as hepatitis, it is important to manage
these conditions as well. Patients must follow doctor's recommendations for treatment and take
any prescribed medications as directed.

● Maintain a healthy diet

Eating a healthy and balanced diet is important for people with cirrhosis. A diet rich in fruits,
vegetables, whole grains, and lean protein sources can help support liver function and reduce the
risk of complications.

● Manage symptoms

Cirrhosis can cause a range of symptoms such as fatigue, itching, and swelling in the legs and
abdomen. Physicians may prescribe medications or recommend lifestyle changes to help manage
these symptoms.

● Get vaccinated

Vaccinations for hepatitis A and B can help prevent further liver damage in people with cirrhosis.

● Avoid certain medications

Certain medications can be harmful to the liver and should be avoided if a patient has cirrhosis.
Consult the physician or pharmacist before taking any over-the-counter medications or
supplements.

● Regular check-ups
People with cirrhosis need regular check-ups with their doctor to monitor liver function and
detect any complications early.