CASE STUDY

Introduction About Self: - My name is Himani Sangwan, M. Sc Nursing 1st year student of ILBS Nursing College. I was
posted in private ward, Phase-2 fifth floor of ILBS hospital Vasant Kunj, from 06/11/23-10/11/23 as a part of my clinical
experience.

Introduction About The Client: - Mr. Vishnu Kant , 34 years old resident of Indra nagar , Lucknow, Uttar Pradesh. He was
admitted on 02 nov 2023 in private ward with the diagnosis of CLD NASH.

Reason For Selecting This Topic For Case Study: - I found my client’s case interesting and therefore, I selected CLD NASH
as my topic for case study. This will enable me to learn the comprehensive care required by such patients and therefore
enable me to develop and refine my nursing care skills including the management.

Informant :- Patient and his wife .

SOCIO DEMOGRAPHIC PROFILE

Name : Mr. Vishnu Kant

Age : 34 years

Sex : Male

Education : Hindu

Occupation : Own business

Mother tongue : Hindi

Address : Lucknow (U.P)

Ward : private ward

IP No. / UHID No. : 331860/95273

Diagnosis : CLD NASH

Date of admission : 02/11/2023

Treating physician : Dr. Rakhi Maiwall

CHIEF COMPLAINTS AT THE TIME OF ADMISSION:

Chief Complaints:

Condition on admission

 Ascites
 Abdominal pain since 1 month
 Fever and vomiting since 15 days
 Shortness of breath since 1 day
 Cough since 3 days
 Jaundice since 10 days
 Pedal edema since 15 days

History of present illness:

Patient was having abdominal pain from August 2023 which was progressive. Then patient took treatment from
Past health history

Patient developed hypertension and hypothyroidism

Past surgical history

Past surgical history is not significant.

Personal history

● Diet and nutrition: non-vegetarian. Appetite is adequate. ● Elimination patterns: Normal elimination patterns. ● Sleep
pattern: Adequate. ● Activity and rest pattern: Patient only perform passive exercises because of abdominal distension. ●
Substance use: Patient takes alcohol (last intake 10 days before). SHe also smokes. ● Leisure activity: Patient talks with
her family. ● Sexual and reproductive history: Normal reproductive status. The family members have no hereditary
problems related to reproduction. ● Occupation history: She is self-employed, stays with her family. ● Medication
history: Patient was taking medications for CLD NASH on OPD basis. ● Allergic reaction: No H/O any drug allergy/ food
allergy. ● Immunization: No H/O of immunization. Social history

● Birth history: Agra

● Residence: Agra

● Education: graduate

● Marital status: Married

Family history

● Type of family: Nuclear

● Total no of members: 5

● Number of dependents: 3

● Family pedigree:

S.no Name Relation Age/sex Education Occupation Health status

Family disease: No history of DM/HTN hypothyroidism/CAD/Cancer and any psychiatric illness

in the family. PHYSICAL EXAMINATION

Date of physical assessment performed: 14/11/2022

General appearance

● Body built: Obese

● Nourishment: Well nourished

● Level of consciousness: Conscious

● Hygiene: Maintained

● Activity: Passive range of motion

Vital signs

S.NO HR Rhythm RR Blood Pressure Temp SPO2

D Anthropometric Measurement

● Height: 158cm

● Weight: 84kg

● BMI: 33.6kg/m2

Head to Toe Examination

Skin

S.no Name Relation Age/sex Education Occupation Health

Status

1 Mr. Rajesh Husband 57 yr/male Graduate Business Healthy

2 Mrs. Sangeeta

Patient 55yrs/female Graduate Teacher Unhealthy

3. Mr. Anuj Son 28yrs/male Graduate Business Healthy

4. Mrs. Anusha Daughter 25 yrs/male Graduation Teacher Healthy

● Color: Skin is

● Texture: Skin is dry

● Temperature: 98.6

● Lesions: No macules, papules, vesicles present

● Clubbing: Not present

● Edema: Oedema over feet

Head

● Color of hair: Black

● Shape of skull: Normal

● Scalp: Clear

● Pediculosis: No pediculosis

● Texture: Texture is soft

● Hair distribution: Less

Face

● Shape: Symmetrical, Pale

● Oedema: No facial/Ocular edema

● Hydration: Face is hydrated

● Any abnormality: No any other abnormality

Eye

● Vision: No Myopia/ diplopia/ hypermetropia

● Eyebrow: Both eyebrow is in symmetrical shape

● Eye lashes: There is no evidence of eye infection

● Eyelid: Normal No stye/swelling/ptosis

● Eyeball: Eye ball is round in shape and not protruding/ Not

sunken/No exophthalmos.

● Conjunctiva: Pink/ no conjunctivitis

● Sclera: normal

● Cornea & Iris: Symmetrical

● Pupil: Pupil is reactive

● Lens: No opaqueness/ no crust formation

Ear

● Hearing: Patient is able to hear properly.

● External ear: Clear ear

● Tympanic membrane: There is no perforation

● Discharge: No discharge from Ear

Nose and Sinus

● Nostrils: Nostrils are normal clean

● Nasal septal deviation: There is no septal deviation

● Discharge: No discharge is present from nose

● Any bleeding from nose: No bleeding is present

● Sinus: Sinus is normal

Mouth

● Lips: Symmetrical, no cyanosis. ● Odor of mouth: No odour present

● Teeth: white teeth

● Mucous membrane & gums: There is no swelling present

● Tongue: Dry

● Tonsils: No inflammation or ulceration of tonsils

Neck

● Nuchal rigidity: Not present

● Lymph node: No lymphadenopathy

● Thyroid gland: Not palpable

● Trachea: Midline

● Carotid pulse: Palpable/No distension is present

Chest:

● Scar: No scar present

● Symmetry: Symmetrical in shape

● Colour: Normal skin colour

● Lesion: No lesion

● Chest: Symmetrical in shape & no gynecomastia, Barrel chest. Axilla

● Redness: Not present

● Lumps: Absent

● Rash: Absent

● Lymph node: Not enlarged

SYSTEMATIC EXAMINATION

Neurological system

● Coordination test: Normal

● Reflexes: Normal

● Test for sensation: Normal

● GCS: 15(E4V5M6)

Respiratory system

 Inspection: Symmetrical  Barrel chest: Absent  Breathing pattern: Normal  Palpation: No tenderness  Percussion:
No free fluid present

Cardiovascular system
● Inspection and palpation: Tensed and Distended

● Auscultation: S1 and S2 normal, no murmur present

● Heart rate: 84b/m

● Pain: no chest pain

Abdomen

● Inspection : Distended and no scars noted

● Auscultation : Hypoactive bowel sounds

● Percussion : Dull, free fluid present

● Palpation : Soft, no tenderness or rebound tenderness, guarding, rigidity present

● Abdominal Girth : 98cm

Genitalia & Rectum

● STD’s: Absent

● Any abnormalities: Absent

● Haemorrhoids: Absent

● Pelvic masses: Absent

● Rectal polyps: Absent

Extremities

● Movements: Voluntary movements are present

● Tremors: Absent

● Oedema: Present

● Reflexes: Absent

● Varicose vein: Absent

● Clubbing of the fingers: Absent

● Calf muscle pain: Absent

● Homan’s sign: Negative

Spine

● Spine bifida: Absent

● Scoliosis/kyphosis/lordosis: No scoliosis found

● Curvature: Normal

● Sacral region: No scoliosis found

Impression

Abdomen was tensed and free fluid was present.

INVESTIGATION

1. Laboratory investigation

2. Radiological investigation

3. Others

Laboratory investigation

Radiological Examination

Chest X-ray

 Rotation is normal  Bilateral lung Parenchyma are clear  Both hila and mediastinum appear normal  Domes of
diaphragm are normal  Bony cage and soft tissue are unremarkable

USG Abdomen

 Impression: Chronic liver disease with findings suggestive of portal hypertension

 Splenomegaly with prominent splenoportal axis and gross ascites. Endoscopy

 Eradicated oesophageal varices  Mild PHG

Medications:

S.N Name of Drug Frequency Dose Route

o

Drug Dose Action Indications Contraindication Side effects Nursing

responsibilities

NON-ALCOHOLIC STEATOHEPATITIS

Non-alcoholic fatty liver disease (non-alcoholic fatty liver disease, NAFLD) is the accumulation

of abnormal amounts of fat within the liver. Non-alcoholic fatty liver disease can be divided into
isolated fatty liver in which there is only accumulation of fat, and non-alcoholic steatohepatitis

(NASH) in which there is fat, inflammation, and damage to liver cells. NASH progresses to scarring and ultimately to
cirrhosis, with all the complications of cirrhosis, for example, gastrointestinal bleeding, liver failure, and liver cancer. The
development of non- alcoholic fatty liver disease is intimately associated with and is probably caused by obesity and

diabetes although sometimes it occurs in individuals who are neither obese nor diabetic. Non- alcoholic fatty liver disease
is considered a manifestation of the metabolic syndrome. Epidemiology: -

It is currently estimated that the global prevalence of NAFLD is as high as one billion. In the

United States, NAFLD is estimated to be the most common cause of chronic liver disease, affecting between 80 and 100
million individuals, among whom nearly 25% progress to NASH

Risk factors:

Book picture Patient picture

NASH is most common in patients who are
overweight or obese. Other risk factors include:
● Diabetes
● High cholesterol
● High triglycerides
● Poor diet
● Metabolic syndrome, Polycystic ovary syndrome
● Sleep apnea
● Underactive thyroid (hypothyroidism)

Causes :

Book picture Patient picture

 overweight or obesity
● insulin resistance or type 2 diabetes
● abnormal levels of fats in your blood, which may include
● high levels of triglycerides
● abnormal levels of cholesterol—high
total cholesterol, high LDL cholesterol, or low HDL
cholesterol
● metabolic syndrome or one or more
traits of metabolic syndrome. Metabolic
syndrome is a group of traits and
medical conditions linked to overweight
and obesity. define metabolic syndrome
as the presence of any three of the
following
 Large waist size  High levels of triglycerides in blood
 Low levels of HDL cholesterol in blood
 High blood pressure  Higher than normal blood glucose
levels or a diagnosis of type 2 diabetes

Signs and symptoms:

Book picture Patient picture

Sign& Symptoms  Intense itching
 Ascites  Bruising and bleeding easily
  Jaundice  Spider-like blood vessels just beneath
your skin’s surface  Oedema  Behaviour changes,
slurred speech, and
confusion (hepatic encephalopathy)
If someone with NAFLD/NASH develops
cirrhosis they are also at some risk of
developing a common type of liver cancer
called hepatocellular carcinoma.

Diagnosis :

Book picture Patient picture

● Blood investigations
Liver Function Tests: Direct bilirubin, indirect
bilirubin, Total bilirubin, Serum albumin, Serum
globulin, Total protein. Platelet counts, PT/INR
● USG abdomen
● NCCT- abdomen
● Endoscopy
Upper GI endoscopy: For the diagnosis of
esophageal varices. Sigmoidoscopy: For the diagnosis of
rectal
varices
● Liver Biopsy
● Endoscopic retrograde
cholangiopancreatography (ERCP): It is
an endoscopic procedure that combines
upper gastrointestinal (GI) endoscopy
and fluoroscopy to diagnose and treat
problems of the bile and pancreatic
ducts. ● Model for end-stage liver disease
(MELD) score
It is calculated according to the following
formula: - MELD = 3.78×ln[serum bilirubin (mg/dL)] +
11.2×ln[INR] + 9.57×ln[serum creatinine
(mg/dL)] + 6.43
● If the patient has been dialyzed twice
within the last 7 days, then the value for
serum creatinine used should be 4.0
mg/dL. ● Any value less than one is given a value
of 1. Interpretation
In interpreting the MELD Score in hospitalized
patients, the 3 month observed mortality is
● 40 or more : 71.3% observed mortality.
● 30 - 39 : 52.6% observed mortality
● 20- 29 : 19.6% observed mortality
● 10 - 19 : 6.0% observed mortality
● <9 : 1.9% observed mortality

Management :

Book picture Patient picture

Depending on the cause
● Viral Hepatitis such as hepatitis B
and C
Hepatitis B
Pegylated interferon, lamivudine, adefovir
dipivoxil, entecavir, telbivudine, tenofovir. Hepatitis C
NS3/4A protease inhibitors, including
telaprevir, boceprevir, simeprevir, and
others
NS5A inhibitors, including ledipasvir, daclatasvir, and
others
NS5B polymerase inhibitors, including
sofosbuvir, dasabuvir, and others
These drugs are used in various
combinations, sometimes combined with
ribavirin based on the patient's genotype. ●
Hemochromatosis: Phlebotomy, chelation therapy using
drugs such
as deferoxamine, deferasirox
● Wilson disease
Penicillamine is a chelating agent that binds
copper and leads to excretion of copper in
the urine. Zinc (usually in the form of a zinc acetate
prescription called Galzin) may be used. Zinc stimulates
metallothionein, a protein in
gut cells that binds copper and prevents
their absorption and transport to the liver. Liver
transplantation is an effective cure for
Wilson disease. ● Primary sclerosing cholangitis
Moderate doses (13-15 milligrams per
kilogram) of ursodeoxycholic acid (UDCA)
is recommended by the European
Association for the Study of the Liver.
Supportive therapy include antipruritics
(e.g. bile acid sequestrants such as
cholestyramine); antibiotics to treat
episodes of ascending cholangitis; and
vitamin supplements such as Vitamin A,D, E, K as people
with PSC are often deficient
in fat-soluble vitamins.Liver transplantation
is the only proven long-term treatment of
PSC.Indications for transplantation include
recurrent bacterial ascending cholangitis, decompensated
cirrhosis, hepatocellular
carcinoma, hilar cholangiocarcinoma, and
complications of portal hypertension. ● Primary Biliary
cholangitis
It is indicated for the treatment of PBC in
combination with ursodeoxycholic acid
(UDCA) in adults with an inadequate
response to UDCA, or as monotherapy in
adults unable to tolerate UDCA. cholestyramine (a bile
acid sequestrant)
 may be prescribed to absorb bile acids in
the gut and be eliminated, rather than re- enter the
bloodstream. Vitamin supplementation such as A,D,E,K. In
advance cases, liver transplantation is an
option. Supportive therapy
● Blood products especially packed
red blood cells (PRBC), fresh frozen
plasma (FFP) in view of low platelet
count and anemia. ● Vitamin K
Vitamin K is required for the synthesis of
functionally active forms of a number of
coagulation factors and inhibitors by the
liver, including prothrombin, factor VII, XI, X, protein C,
and protein S. Thus, coagulation abnormality is a
predictable
feature of acute as well as chronic liver
disease. Thus, vitamin K is prescribed for
the patients with chronic liver disease. ● Acetylcysteine
N-acetylcysteine (NAC) is a
hepatoprotective agent that turns into the
amino acid L-cysteine when ingested. In turn, L-cysteine
helps produce glutathione
(GSH) that helps produce the
antioxidant glutathione, which plays a key
role in protecting the liver from damage. ● Administration
of albumin in view
of hypoalbuminemia and ascites. ● Abdominal
paracentesis
Therapeutic paracentesis refers to the
removal of five liters or more of fluid to
reduce intra-abdominal pressure and relieve
the associated dyspnea, abdominal pain, and
early satiety
● Fecal Microbiota (FMT)
Fecal Microbiota transplantation (FMT) is
the administration of a solution of fecal
matter from a donor into the intestinal tract
of a recipient in order to directly change the
recipient’s gut microbial composition either
by colonoscopy, enema, orogastric tube or
by mouth in the form of a capsule
containing freeze-dried material.

Surgical management :

Book picture Patient picture

● Liver transplant is the universal
definite treatment for end stage liver
disease (ESLD) or cirrhosis as a result
of chronic liver disease which replaces
a failing or damaged liver with a
healthy and well-functioning one.
Complications :

Book picture Patient picture

● Portal hypertension: Portal
hypertension is high blood pressure in
the hepatic portal system. A normal
HVPG is between 1 and 5 mmHg. Portal hypertension is
present if the
HVPG is ≥6 mmHg. Portal
hypertension typically becomes
clinically significant when the HVPG
is ≥10 mmHg, at which point varices

● Ascites
● Hypoalbuminemia

may develop. Once the HVPG is ≥12

mmHg, patients are at risk for variceal
bleeding and the development of
ascites. ● Ascites : Accumulation of fluid in the
peritoneal cavity results in ascites
● Hypersplenism (with or without
splenomegaly)
Liver and spleen are closely associated via the
portal vein system. Portal hypertension in chronic liver
disease can lead to congestion of the portal system and
therefore hypersplenism and splenomegaly occurs.
● Lower oesophageal varices: extremely dilated
submucosal veins in the lower
third of the esophagus and have a strong tendency to
develop bleeding.
● Rectal varices : Dilation of collateral submucosal veins
● Hypoalbuminemia: Albumin is synthesized in the liver
and thus liver disease causes hypoalbuminemia.
● Coagulopathy
Liver is the site of synthesis of clotting factors, coagulation
inhibitors, and fibrinolytic proteins. Therefore, the most
common coagulation disturbances occurring in liver
disease include thrombocytopenia and impaired humoral
coagulation.
● Hepatopulmonary syndrome: It is characterized by the
triad of abnormal arterial oxygenation caused by
intrapulmonary vascular dilatations (IPVDs) in the setting
of liver disease, portal hypertension, or congenital
portosystemic shunts.
● Hepatorenal syndrome, HRS is a life-threatening medical
condition that consists of rapid deterioration in kidney
function in individuals with cirrhosis or fulminant liver
failure.
● Hepatic Encephalopathy: It describes a spectrum of
potentially reversible neuropsychiatric abnormalities seen
in patients with liver dysfunction and/or portosystemic
shunting.
● Hepatocellular carcinoma:
 Hepatocellular carcinoma (HCC) is a primary tumour of the
liver that usually develops in the setting of chronic liver
disease, particularly in patients with cirrhosis and chronic
hepatitis B virus or hepatitis C virus infection.
Nursing Management :

Nursing Assessment

● Assess vital signs. Patient can have fever with chills, hypotension, or tachycardia. ● Review serum sodium and
potassium levels, which may become depleted with

nasogastric suctioning or fluid shifts. ● Review serial WBC count and differentiation to evaluate the course of action. ●
Assess tissue perfusion. Note level of consciousness, skin color and temperature, pulses, and capillary refill. ● Assess
hydration status: note skin turgor on inner thigh or forehead, condition of buccal

membranes, and development of oedema or crackles. ● Assess the patient’s abdomen for resolution of rigidity, rebound
tenderness, and

distention. Auscultate bowel sounds.

Nursing Diagnosis

● Ineffective breathing pattern related to increased abdominal distension

● Impaired nutritional status related to anorexia and underlying disease condition.

● Fluid volume excess related to intravascular fluid shift to the peritoneal space and edema.

● Ineffective peripheral tissue perfusion related to anaemia and prolonged bed rest

● Risk for sepsis related to worsening disease conditions.

● Risk for infection related to invasive lines in situ .

Nurse’s Progress Notes:

Date and Day Condition of Patient

Day 1 ● Vital signs of the patient recorded carefully. ● Hygiene of the patient is well
maintained. ● Patient’s haemodynamic parameters charted on hourly
basis
● Paracentesis was assisted. ● Medication administration done as per the orders by
the doctor.
Day 2 ● Vital signs of the patient recorded carefully. ● Hygiene of the patient is well
maintained. ● Medication administration done as per the orders by the

doctor. ● Maintained intake-output hourly chartings.

Day 3 ●Vital signs of the patient recorded carefully. ● Hygiene of the patient is well
maintained. ● Medication administration done as per the orders by the doctor. ●
Maintained intake-output hourly chartings. ● Bed bath given and all dressings
changed under aseptic conditions.

Health education :-

DIET: Low salt, high protein, normal diet is recommended for the client. Following foods are recommended:

● Whole grains in the form of bran, whole wheat bread or cereal, brown rice, whole grain

pasta or porridge, whole oats, wild rice, rye, oatmeal and corn. ● Fruits and vegetables
● Olive oil, canola oil and flaxseed oil

● Healthy proteins in the form of low-fat milk, dairy products along with lean meats, beans, eggs and soy products

● Low fat dairy products: milk, yogurt and cheese.

● High fiber foods such as vegetables, fruits, nuts, legumes (beans, peas and lentils), whole- wheat flour and wheat bran.
● Foods containing monounsaturated and polyunsaturated fats includes avocados, almonds, pecans, walnuts, olives, and
canola, olive and peanut oils (Lower cholesterol levels)

b) PHYSICAL ACTIVITY AND EXERCISE

Under the guidance of a physiotherapist, the client performs diaphragmatic breathing exercises, coughing exercises,
spirometry, passive ROM exercises. He also goes for walk with the

assistance of nursing personnel and GDAs. c) MEDICATIONS

Health education regarding his pharmacological management given (name of the drug, dose, route and precautions that
needs to be taken) and clarified his doubts. d)PREVENTION OF COMPLICATIONS

1. Liver rejection: Educated client for the sign and symptoms of organ rejection such as fever

greater than 100° F/38.4° C, flu-like symptoms such as chills, nausea, vomiting, diarrhoea, loss

of appetite, headaches, dizziness, body aches, tiredness, abdominal pain or tenderness. 2. Educated about prevention of
infection

Hand washing:

Practice good hand washing techniques. Encourage any family and friends who are in contact

with client to practice good hand washing techniques. Wash hands well before caring for any

wounds or doing any dressing changes. Report any changes in the wound (increased redness, swelling, or drainage).
Contacts:

Avoid close contact with people who have obvious illnesses such as colds and flu. Avoid crowds, particularly when in a
closed area, during cold and flu season or when you are highly

immunosuppressed. Do not share eating utensils, cups, and glasses with others since many viral

illnesses are spread through saliva and mucous. Do not share razors or toothbrushes.

Conclusion:

I pooja student of M.Sc. Nursing 1st year was posted in private Ward, from 14/11/22-19/11/22. There I took this patient
Mrs. Sangeeta yadav , 55 years old for my case study and is a known

case of CLD NASH. The patient was admitted with complaints of ascites,hematochezia, weight

gain, swelling over legs. I gave him care for 3-4 days care while preparing for this NCP and I came to know the disease

condition and correlate it with the book clinical manifestation, diagnostic evaluation and

Treatment. On my last day of patient care the patient's condition was stable. Bibliography:

1) Lippincott, manual of nursing practice, edition 8th publisher Jaypee brothers Pp. 1075- 1077.

2) Brunner &Suddarth’s, Medical Surgical Nursing. 10th Edition: Pp-1113-1116.

3) PubMed:http://www.pubmed.org

4) Joyce M. black, eighth edition, volume 2, Medical surgical nursing.