NURSING CARE

IN PATIENTS WITH HEPATIC CIRRHOSIS WITH ESOPHAGAL VARICES

Prepared to fulfill the assignments for the Nursing English course
Lecturer: Nina Rosdiana, S.Kep..M.Kep.

Arranged by :
Elsa Sa'adatunnisa 1420122088
Afni Indriyani 1420122090
Melia Nur Fadila 1420122112
Siti Nurohmah 1420122083
Dea Nurul Hamidah 1420122194
Rindi Deslita Ikwanti 1420122108
Magdalene Ring 1420122132
Putri Apriliyanti 1420122137
Nabila Mutikarima 1420122175

NURSING SCIENCE STUDY PROGRAM

FACULTY OF HEALTH SCIENCES
GALUH UNIVERSITY
2023/2024
 CASE
Patient Mr M (34 years old) was medically diagnosed with Cirrhosis Hepatis with Esophageal
Verises. In 2009, the patient was diagnosed with Hepatitis B (+), the stomach distended
repeatedly three times. The patient has undergone ligation four times, the last being on July 30
2009. Currently the patient complains of feeling full in the stomach, pain in the pit of the
stomach, nausea(-), History of melena(-) Physical Examination results Vital signs: BP: 90/60
mmHg, P: 88 times/minute, RR: 22 times/minute, and T: afebrile. The stomach looks distended,
feels tense, bowel sounds 8 times/minute, ascites(+) results of supporting examinations: PT:
25, Fibrinogen: 50 mg/dl, D-Dimer: 3500 mg/dl, HB: 10.6 mg/dl , Ht: 32, Leukocytes: 4.1,
Platelets: 5300, Erythrocytes: 3.15 Endoscopy results: esophageal varices were visible.
1. Assessment
A. Client Identity
Name : Mr M
Age : 34 years old
gender : Male
Status : Married
Education : Equivalent
Occupation : Enterpreuner
Religion : Islam
Ethnicity : Indonesian
Address : Ciamis
Date of entry : 28 August 2010
Study date : 28 August 2010
Source of Costs : Family
Source of information : Family
Room : 2 A jasmine
Diagnosis : Cirrhosis Hepatis with esophageal varices

B. Identity of the person in charge

Name : Mrs. D
Age : 30 years old
Gender : Female
Relationship with family : Wife
Occupation : Housewife
Address : Ciamis

C. Medical history
1. Chief Complaint and Current Health History
The client currently complains of stomach ache, pain in the pit of the
stomach, nausea (-), history of melena (-). The client was admitted to the
hospital on August 28 2010 with complaints of stomach ache and pain in the
pit of the stomach.
2. Previous medical history

1
 In 2009, the patient was diagnosed with Hepatitis B (+), the stomach
distended repeatedly three times. The patient has undergone ligation four
times, the last being on July 30 2009.
3. Family health history
The client's family said that no one had experienced the disease that the
client is currently experiencing.

D. Daily living activity history

No Need Before getting After being sick
sick
1. Nutrition
a) BB/TB 60Kg/148cm 60Kg/148cm
b) Chewing ability Normal Normal
c) Meal frequency 2x a day 1x a day
d) Meal portion 1 serving 1 serving
e) Appetite: good/not good Good Good

f) Diet food

There isn't any Fats and

undercooked
(raw) foods
2. Fluid
a. Intakes
 Orally Water Water
± 1,600 ml/day ± 1,000 ml/day
 Intravenous - Nacl infusion
20
drops/minute

3. Elimination
a. BAK
 Frequency 4-5 x a day 4-5 x a day
 Consistency Liquid Liquid
 Color Clear yellow Clear yellow
b. CHAPTER
 Frequency 1-2 x a day 1 x a day
 Consistency Congested Congested
 Color Yellow Yellow

4. Rest sleep
a. Long sleep 8 hours 8 hours
b. Difficulty sleeping There isn't any There isn't any
c. Sleep habits Evening Evening
5. Personal Hygiene
a. Bathe 2x a day 1x a day
b. Brush your teeth 2x a day 1x a day
c. Nail clipper 2x a week -

2
 6. Activity
a. Physical mobilization Activities as Assisted by
usual family or nurse
There is
b. Difficulty carrying out There isn't any
activities

E. Physiological data
The client's condition appears anxious and agitated, speaks clearly and the client
can adapt well to the care environment.
F. Social data
Clients can interact with nurses, doctors and families.
G. Spiritual data
The client knows that the illness he is suffering from is a trial from Allah SWT
and the client is confident that he will recover.
H. Physical examination
1) General condition
TTV results
BP : 90/60 mmHg
P : 88 times/minute
RR : 22 times/minute
T : afebrile

2) Respiratory system
The breathing pattern is fast and shallow, with a frequency of 22
times/minute
3) Cardiovascular System
The client's conjunctiva is pale and his pulse rate is 88 beats/minute.
4) Nervous system
The client does not experience disturbances in the central nervous
system, the level of consciousness is compos mentis, there is a response
to pain in the abdomen.
5) Urinary system
Dark urine color
6) Digestive system
Stomach feels full, increased abdominal girth, distended stomach.
7) Integumentary system
There are sunken eyes, pale skin color, decreased skin turgor
8) Musculoskeletal system
There are no signs of fracture or dislocation

I. Supporting data
1) PT : 25
2) Fibrinogen : 50 mg/dl
3) D-Dimer : 3500 mg/dl

3
 4) HB : 10.6 mg/dl
5) HT : 32
6) Leukocytes : 4.1
7) Platelets : 5300
8) Erythrocytes : 3.15
9) Endoscopy results : esophageal varices were visible

J. Head toe check

1) Head and face
There are no lumps on the head and face, no lesions on the head, hair falls
out easily.
2) Eye examination
The conjunctiva appears pale
3) Ear examination
The ears look clean, the patient's hearing is not good.
4) Nose examination
Nose looks clean.
5) Examination of the mouth and pharynx
The patient's mouth looks clean.
6) Neck examination
There was no enlargement of jugular venous distension
7) Thoracic examination
Inspection : symmetrical left and right chest, no use of accessory muscles
for breathing
Auscultation : vesicular sounds
Palpation : left and right fremitus
Percussion : sounds sonor
8) Cardiovascular system examination
Inspection : Ictus cordis is not visible
Auscultation : regular heart rhythm
Palpation : ictus cordis is palpable

9) Abdominal examination
Inspection : The stomach appears enlarged
Auscultation : bowel sounds 8 times/minute
Palpation : the liver is palpable and painful
Percussion : sounds dull at the border of the liver

K. Data analysis
No Data Etiology Problem
1. DS: Peritoneal Acute pain
 The patient reported inflammation
pain in the stomach
and felt bloated

4
  Pain in the solar
plexus
Do:
 The results of the
physical
examination
showed that the
stomach was
distended and felt
tense.

2. DS: Inability to absorb Risk of nutritional

 The patient said his nutrients deficit
stomach was full
Do:
 Ascites (+)
3. DS: Decreased HB Ineffective
 - concentration peripheral
Do: perfusion
 The HB value
decreased to 10.6
mg/dl
 The HT value
decreased to 32
 The fibrinogen
value decreased to
50 mg/dl
 Pale skin color,
decreased skin
turgor
4. DS: Regulatory Hypervolemia
 - mechanisms
Do:
 Jugular vein
distention
 Hb and Ht levels
decrease
 Respiratory
frequency 22
times/minute or
dipsne
 Blood pressure
decreases
 Sunken eyes
 Ascites (+)

5
L. Nursing diagnoses
a. Acute pain SDKI (D.0077) related to inflammation of the peritoneum and
the patient said that he had pain in the stomach and felt bloated, pain in the
pit of the stomach, and a distended stomach.
b. Risk of SDKI nutritional deficit (D.0032) related to inability to absorb
nutrients and the patient states that the stomach is full and has ascites (+).
c. Ineffective peripheral perfusion SDKI (D.0009) bd decreased Hb
concentration and decreased Hb value, namely 10.6 mg/dl, decreased Ht
value, namely 32, decreased fibrinogen value, namely 50 mg/dl, pale skin
color and decreased skin turgor.
d. Hypervolemia SDKI (D.0022) bd regulatory mechanism dd jugular vein
distension, decreased Hb and Ht levels, respiratory frequency 22
times/minute

6
 M. Nursing Intervention

No Nursing Nursing Outcomes Nursing Intervention

Diagnosis (SLKI) (SIKI)
(IDHS)
1 Acute pain Result Criteria: Pain Management (l.08238)
(D.0071) related  Pain level  Observation
to inflammation of (L.08066): - Identify location, characteristics,
the peritoneum - Pain duration, frequency, quality, intensity
and the patient complaints of pain.
reports pain in the reduced - Identify the pain scale.
stomach and feels (improved) - Identify non-verbal pain.
bloated, pain in - The client's - Identify factors that aggravate and
the pit of the sleep pattern relieve pain.
stomach, and a returns to  Therapeutic
distended regularity - Control the environment that
stomach. aggravates pain.
- Rest and sleeping facilities.
- Consider the type and source of pain in
selecting pain relief strategies.
 Education
- Explain the cause, period, and triggers
of pain.
- Suggest pain relief strategies.

2. Risk of nutritional Result Criteria:  Nutrition Management (I.03119) :

deficit (D.0032)  Nutritional Status  Observation:
inability to absorb (L.03030): - Identify nutritional status
nutrients and the - Identify food allergies and intolerances
patient says the - Feeling full - Identify preferred foods
stomach is full and quickly - Identify calorie needs and types of
ascites (+) (ascites) nutrients
- Stomach - Identify the need for use of a
bloating nasogastric tube
decreases - Monitor food intake
(improves) - Monitor weight
- Monitor laboratory examination results
 Therapeutic:
- Perform oral hygiene before eating, if
necessary
- Facilitation of determining dietary
guidelines (e.g. food pyramid)
- Serve food attractively and at
appropriate temperatures

7
 - Provide foods high in fiber to prevent
constipation
- Provide foods high in calories and high
in protein
- Give food supplements, if necessary
- Discontinue nasogastric tube feeding if
oral intake is tolerated
 Education
- Encourage a sitting position, if possible
- Teach the programmed diet
 Collaboration
- Collaborative administration of
medication before meals (eg pain
relievers, antlemetics). If necessary
- Collaborate with a nutritionist to
determine the number of calories and
types of nutrients needed, if necessary
3. Ineffective Result criteria:  Laboratory results monitoring (I.02057):
peripheral  Peripheral  Observation
perfusion SDKI perfusion - Identify required laboratory tests
(D.0009) bd (L.02011): - Monitor required laboratory results
decreased Hb - Blood pressure - Check the suitability of laboratory
concentration dd rises results with the patient's clinical
decreased Hb (improves) appearance
value namely 10.6 - The amount of  Therapeutic
mg/dl, decreased Hb, Ht and - Take blood/sputum/pus/tissue samples
Ht value namely fibrinogen or other samples according to protocol
32, decreased improved - Interpret laboratory test results
fibrinogen value - Peripheral  Collaboration
namely 50 mg/dl, edema - Collaborate with a doctor if laboratory
pale skin color and decreases results require media intervention
decreased skin - Decreased
turgor extremity pain
- Skin turgor
improves
4. SDKI Result criteria:  Hypervolemia Management (I.03114):
hypervolemia  Fluid Balance  Observation
(D.0022) related (L.05020) : - Check for signs and symptoms of
to regulatory - Ascites hypervolemia (e.g. orthopnea, dyspnea,
mechanisms and decreases edema, increased JVP/CVP, positive
jugular vein - Blood pressure hepatojugular reflex, additional breath
distension, improves sounds)
decreased Hb and - Sunken eyes - Identify the cause of hypervolemia
Ht levels, improve - Monitor hemodynamic status (e.g.
respiratory - Skin turgor heart rate, blood pressure,
frequency 22 improves MAP,CVP,PAP,PCWP,CO,CI), if
times/minute. - Skin color available
improves - Monitor fluid intake and output

8
 - Monitor signs of hemoconcentration
(e.g. sodium levels, BUN, hematocrit,
urine specific gravity)
- Monitor for signs of increased plasma
oncotic pressure (e.g. increased protein
and albumin levels)
- Monitor infusion rate closely
- Monitor for diuretic side effects (e.g.
orthostatic hypotension, hypovolemia,
hypokalemia, hyponatremia)

 Therapeutic
- Weigh yourself every day at the same
time
- Limit fluid and salt intake
- Elevate the head of the bed 30-40°

 Education
- Advise to report if urine output is <0.5
mL/kg/hour within 6 hours
- Recommend reporting if body weight
increases >1kg in a day
- Teach how to measure and record fluid
intake and output
- Teach to limit fluids
 Collaboration
- Collaborative administration of
diuretics
- Collaborative replacement of
potassium loss due to diuretics
- Collaborative administration of
continuous renal replacement therapy
(CRRT), if necessary

9
 N. Implementation

No TIME NURSING DIAGNOSES IMPLEMENTATION INITIALS

1 August 28, Acute pain (D.0071) related Pain management
2010 to inflammation of the  Observation
07.00 WIB peritoneum and the patient - Identify the location, characteristics,
reports pain in the stomach duration, frequency, quality,
and feels bloated, pain in intensity of pain
the pit of the stomach, and - Identify the pain scale
a distended stomach - Identifying non-verbal pain
responses
- Identify factors that aggravate and
relieve pain
- Identifying knowledge and beliefs
about pain
- Identifying cultural influences on
pain responses
- Identifying the influence of pain on
quality of life
 Therapeutic
- Controlling environments that
aggravate pain (e.g. room
temperature, lighting, noise)
- Facilitates rest and sleep
- Consider the type and source of pain
in selecting pain relief strategies
 Education
- Explain the causes, periods and
triggers of pain
- Explain pain relief strategies
- Encourage self-monitoring of pain
- Recommend appropriate use of
analgesics
- Teaching non-pharmacological
techniques to reduce pain
2. August 28, Risk of nutritional deficit Nutrition management
2010 (D.0032) inability to absorb  Observation
07.00 WIB nutrients and the patient - Identify nutritional status
says the stomach is full and - Identify food allergies and
ascites (+) intolerances
- Identify preferred foods
- Identify calorie needs and types of
nutrients
- Identify the need for use of a
nasogastric tube
- Monitor food intake
- Monitor body weight
- Monitor laboratory examination
results
 Therapeutic

10
 - Perform oral hygiene before eating,
if necessary
- Facilitates determining dietary
guidelines (e.g. food pyramid)
- Serves food attractively and at the
appropriate temperature
- Provide foods high in fiber to
prevent constipation
- Provide foods high in calories and
high in protein
- Provide dietary supplements, if
necessary
- Discontinue feeding via nasogastric
tube if oral intake can be tolerated
 Education
- Encourage a sitting position if
possible
- Recommend a programmed diet
 Collaboration
- Collaborate with administration of
medication before meals (e.g. pain
relievers, antlemetics), if necessary
- Collaborate with a nutritionist to
determine the number of calories
and types of nutrients needed, if
necessary
3. August 28, Ineffective peripheral Monitoring Laboratory Results
2010 perfusion SDKI (D.0009)  Observation
07.00 WIB bd decreased Hb - Identify required laboratory tests
concentration dd decreased - Monitor required laboratory results
Hb value namely 10.6 - Check the suitability of laboratory
mg/dl, decreased Ht value results with the patient's clinical
namely 32, decreased appearance
fibrinogen value namely 50  Therapeutic
mg/dl, pale skin color and - Take blood/sputum/pus/tissue
decreased skin turgor samples or other samples according
to protocol
- Interpret laboratory test results
 Collaboration
- Collaborate with a doctor if
laboratory results require medical
intervention
4. August 28, SDKI hypervolemia Management of hypervolemia
2010 (D.0022) related to  Observation
07.00 WIB regulatory mechanisms and - Check for signs and symptoms of
jugular vein distension, hypervolemia (e.g. orthopnea,
decreased Hb and Ht levels, dipsnea, edema, increased
respiratory frequency 22 JVP/CVP, positive hepatojugular
times/minute. reflex, additional breath sounds)
- Identify the causes of hypervolemia

11
 -Monitor hemodynamic status (e.g.
heart rate, blood pressure, MAP,
CVP,PAP, PCWP,CO, CI) if
available
- Monitor fluid intake and output
- Monitor signs of hemoconcentration
(e.g. sodium levels, BUN,
hematocrit, urine specific gravity)
- Monitor for signs of increased
plasma oncotic pressure (e.g.
increased protein and albumin
levels)
- Monitor infusion rate closely
- Monitor for diuretic side effects
(e.g. orthostatic hypotension,
hypovolemia, hypokalemia,
hyponatremia)
 Therapeutic
- Weigh yourself every day at the
same time
- Limit fluid and salt intake
- Elevate the head of the bed 30-40°
 Education
- Recommend reporting if urine
output is <0.5 mL/kg/hour within 6
hours
- Recommend reporting if weight
increases >1 kg in a day
- Teaches how to measure and record
fluid intake and output
- Teaches how to limit fluids
 Collaboration
- Collaborating on the administration
of diuretics
- Collaborating to replace potassium
loss due to diuretics
- Collaborate on the administration of
continuous renal replacement
therapy (CRRT), if necessary

12
 O. Evaluation
No TIME NURSING DIAGNOSES EVALUATION INITIALS
1. August 31, Acute pain (D.0071) related to S: The patient no longer complains of
2010 inflammation of the peritoneum pain in the pit of the stomach
06.00 WIB and the patient reports pain in the O: The distended stomach is reduced
stomach and feels bloated, pain in and does not feel tense
the pit of the stomach, and a A : Problem resolved
distended stomach P: Intervention is stopped
2. August 31, Risk of nutritional deficit S: The patient no longer complains of
2010 (D.0032) inability to absorb stomach ache
06.00 WIB nutrients and the patient says the O: Ascites improves
stomach is full and ascites (+) A : Problem resolved
P: Intervention is stopped
3. August 31, Ineffective peripheral perfusion S :-
2010 SDKI (D.0009) bd decreased Hb O: Hb value returns to normal 13
06.00 WIB concentration dd decreased Hb grams/dl, normal Ht value 39%,
value, namely 10.6 mg/dl, normal fibrinogen value 250 mg/dl,
decreased Ht value, namely 32, skin color is not pale
decreased fibrinogen value, A : Problem resolved
namely 50 mg/dl, pale skin color P: Intervention is stopped
and decreased skin turgor
4. August 31, Hypervolemia SDKI (D.0022) bd S :-
2010 regulatory mechanism dd jugular O: Blood pressure returns to normal
06.00 WIB vein distension, decreased Hb and 120/90 mmHg, jugular venous
Ht levels, respiratory frequency 22 distension decreases, Hb and Ht
times/minute levels return to normal, namely
13gr/dl and 39%, respiratory
frequency becomes normal, namely
18 times/minute, sunken eyes
decrease, ascites decreases
A : Problem resolved
P: Intervention is stopped

13