GROUP A4 Start

CASE
PRESENTATION
ASCITES SECONDARY TO LIVER ENLARGEMENT
 OVERVIEW 00

01 02 03 04
BIOGRAPHICAL DATA CHIEF COMPLAINT HISTORY OF PRESENT PAST HISTORY
ILLNESS

05 06 07 08
FAMILY HISTORY OF REVIEW OF FUNCTIONAL- COMPLETE PHYSICAL
ILLNESS SYSTEMS HEALTH PATTERNS ASSESSMENT

09 10 11 12
GROWTH AND COURSE IN THE REVIEW OF ANATOMY PATHOPHYSIOLOGY
DEVELOPMENT WARD AND PHYSIOLOGY
ATTERN

13 14 15 16
LABORATORY AND DRUG STUDY TOP 3 NCP DISCHARGE PLAN
DIAGNOSTIC EXAMS
CLIENT’S 01
PROFILE

Name: Patient X
Age: 7 years old
Sex: Male
Birthday: April 16, 2016
Address: Brgy. Libjo, Catarman N. Samar
Religion: Roman Catholic
Admitting Diagnosis: Ascites secondary to liver enlargement
Date of Admission: March 20, 2024
Attending Physician: Dr. Evlin
CHIEF
02
COMPLAINT

ABDOMINAL PAIN
“Masuol ak tiyan na mali gin tusok- tusok, didi sa pusod nagtikang” as verbalized by the patient
HISTORY OF
03
PRESENT ILLNESS

1st Hostpitalization - December 2023

2nd Hospitalization - March 19, 2024

PAST HISTORY 04

• Few fever
• Did not undergo any
surgeries
FAMILY HEALTH 05
HISTORY

No known history of
illnesses
REVIEW OF 06
SYSTEMS

Patterns of Functioning by
Gordon
FUNCTIONAL-
07
HEALTH PATTERNS

1.Health Perception-Health Management Pattern

2.Nutritional Metabolic Pattern
3.Elimination Pattern
4.Activity-Exercise Pattern
5.Sleep-Rest Pattern
6.Cognitive-Perceptual Pattern
7.Self-Perception-Self-Concept Pattern
8.Role Relationship Pattern
9.Sexuality-Reproductive Pattern
10.Coping-Stress Tolerance Pattern
11.Value-Belief Pattern
COMPLETE PHYSICAL 08
ASSESSMENT

-Integumentary:

•Skin
Color: Yellowish Dry and dull

•Hair
Color: Black No dandruff/lice Hair evenly distributed on scalp

•Nail
No clubbing of nail
COMPLETE PHYSICAL 08
ASSESSMENT

-HEENT:

•Head
Rounded skull with prominent frontal area and occipital area
No masses/lessions found Face is symmetrical at rest movement

•Eyes
Able to see and recognize mother from strangers
Eyebrows are symmetrical
Pupil follow movement of student nurse
Yellowish sclera
Pupils are reactive to light and accommodation pupils are black in color
COMPLETE PHYSICAL 08
ASSESSMENT

•Ears
Color: same as facial skin
Auricle: aligned with outer canthus of the eye
Able to recognize voices

•Nose and sinuses

Normal Nasal septum intact

•Throat
Lips are pink and dry
Oral mucosal surfaces are normal
Tongue pink in color
Gums: Pink in color, swelling, bleeding not present
COMPLETE PHYSICAL 08
ASSESSMENT

•Neck and lymph nodes

Neck move with discomfort or dizziness

•Respiratory
RR: 42 bpm
Rapid and deep breathing

•Cardiovascular
Pulse rate: 135 bpm
Capillary refill: 2-3 seconds

•Breast and axillae

Aerola: pink in color no discharges, lessions and masses
COMPLETE PHYSICAL 08
ASSESSMENT

•Gastrointestinal
Bowel movement present Color of stool: Yellow, in minimal amount (3x a day)

•Genitourinary
Urine color: Yellow Amount: Minimal amount (1 diaper a day)

•Muskoluskeletal
Muscle wasting

•Language
Able to utter syllabicated words
GROWTH AND
09
DEVELOPMENT

Piaget's theory of cognitive development

COURSE IN THE 10
WARD

• The patient was lying on his back during the duration

of his admission
• On semi-fowler’s position when eating
 ANATOMY AND 11
PHYSIOLOGY

Splee
Liver
n

Gallbladder Stomach

Kidney Heart
PATHOPHYSIOLOGY 12
LABORATORY AND 13
DIAGNOSTIC EXAM

• Glucose concentration
• Lactose dehydrogenase (LDH) concentration
• Gram stain
• Amylase concentration
• Test for tuberculous peritonitis (may be changed)
Cytology
• Triglyceride concentration
• Bilirubin concentration
DRUG STUDY 14

• Acetaminophen
• Hyoscine / scopolamine
• Furosemide
• Cefuroxine
• Metoclopramide
hydrochloride
TOP 3 NCP 15

• Hyperthermia as evidenced by body temperature of 38.1 degrees

celsius, tachycardia, tachypnea, flushed and dry skin, and irritable
mood.
• Ineffective breathing pattern related to increase pressure on the
diaphragm
• Imbalanced Nutrition: Less than body requirements related to
abdominal discomfort as evidenced by abdominal pain, muscle
wasting, lack of appetite, and a body weight of 17 kilograms
DISCHARGE PLAN 16

Medication:
DEPEND ON THE DOCTORS ORDER

1. Diuretics like spironolactone or furosemide to manage

ascites and reduce fluid buildup.
2. Provide medications to address any underlying liver
condition, hepatitis (jaundice with yellow sclera)
3. Ensure the patient understands the dosage, frequency, and
potential side effects of each prescribed medication.
DISCHARGE PLAN 16

Exercise:

1. Recommend low-impact exercises such as walking,

swimming, or cycling to improve circulation and overall
cardiovascular health.
2. Encourage the patient to engage in physical activity for at
least 30 minutes most days of the week, as tolerated.
3. Emphasize the importance of regular movement to prevent
muscle wasting and maintain mobility.
DISCHARGE PLAN 16

Treatment:

1. Discuss treatment options for ascites, such as therapeutic

paracentesis or placement of a transjugular intrahepatic
portosystemic shunt (TIPS), if appropriate.
2. Provide information on lifestyle modifications, including
dietary changes and alcohol cessation, to manage underlying
liver disease and prevent recurrence of ascites.
3. Coordinate with other healthcare providers, such as
hepatologists or gastroenterologists, for specialized care and
ongoing management.
DISCHARGE PLAN 16

Health Teachings:

1. Educate the patient on the importance of adhering to

prescribed medications and following up with their healthcare
provider regularly.
2. Provide information on signs and symptoms to watch for, such
as increased abdominal distention, difficulty breathing, or
changes in mental status, and when to seek medical attention.
3. Offer resources for support groups or counseling services to
address any emotional or psychological challenges associated
with the diagnosis and management of ascites.
DISCHARGE PLAN 16

Observation:

1. Instruct the patient to monitor for signs of worsening

ascites, such as increased abdominal distention, weight gain,
or difficulty breathing.
2. Encourage regular monitoring of vital signs, including blood
pressure, heart rate, and weight.
3. Advise the patient to keep a symptom diary and report any
new or concerning symptoms to their healthcare provider
promptly.
DISCHARGE PLAN 16

Diet:

1. Recommend a low-sodium diet to reduce fluid retention and

manage ascites. Limit salt intake to <2,000 mg per day.
2. Encourage consumption of high-protein foods to support
liver function and promote healing.
3. Provide resources for meal planning and offer guidance on
reading food labels to identify hidden sources of sodium.
DISCHARGE PLAN 16

Spirituality and Sexuality:

1. Address any spiritual or existential concerns the patient may

have related to their illness, and offer support through chaplaincy
services or spiritual counselors if desired.
2. Discuss any concerns or questions regarding sexuality and
intimacy, and provide resources or referrals to appropriate
specialists or support groups if needed.
3. Encourage open communication between the patient and their
partner or caregiver regarding any changes in sexual function or
intimacy related to the illness or its treatment.
 GROUP A4

BARANDINO BAYABAY BELARO BELLO BENESISTO

BERNALDEZ BERONILLA BIANES BOHOL BOLOTANO

GROUP A4 Finish

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