57 years old, is admitted to your unit for observation from the emergency department (ED) with the diagnosis of cirrhosis with possible hepatic encephalopathy. He is lethargic, appears cachectic, and is mildly combative when aroused. He is jaundiced, with a notably distended abdomen. He is receiving an IV infusion of D5 ½ NS.
1. Briefly discuss the pathophysiology of cirrhosis.
2. What are the common causes of cirrhosis?
3. How is hepatic encephalopathy related to cirrhosis?
CASE STUDY PROGRESS
IV D5 ½ NS with 20 mEq KCl at 75 mL/hr
Insert indwelling urinary catheter to gravity drainage
Lactulose 30 mL orally daily
Rifaximin 550 mg orally twice daily
Spironolactone 100 mg orally twice daily
Abdominal ultrasound in a.m.
Vitamin K 10 mg/day IV × 3 doses; change to PO when alert and able to swallow
CBC with differential, BMP, liver function tests, PT/INR and aPTT, serum ammonia (NH3) now and in a.m.
2-Gram sodium diet when alert and able to swallow
Call for any signs of bleeding; systolic BP <100 mm Hg; diastolic BP <50 mm Hg; or pulse >120 beats/min
4. What do you need to do for D.G., and what can you delegate to the UAP?
5. What is the reason for routinely assessing D.G. for bleeding?
6. What assessment findings would indicate the presence of bleeding?
7. Indicate the expected outcome associated with each of the medications he is receiving.
8. What is the rationale for placing him on a low-sodium diet?
CASE STUDY PROGRESS
While you are getting D.G. settled, you continue your assessment.
Neurologic: PERRL; moves all extremities, but is sluggish, pulling away during assessment; follows commands sporadically.
CV: Pulse is regular without adventitious sounds. All peripheral pulses are palpable at 3+ bilaterally; 3+ pitting edema in lower extremities.
Respiratory: Breath sounds clear but diminished in all lobes; musty breath.
GI: Tongue and gums are beefy red and swollen. Abdomen moderately distended, firm, and slightly tender. Bowel sounds positive × 4.
GU: Foley to gravity drainage, with 75 mL dark amber urine past 2 hours.
Skin: Mild jaundice. Skin appears thin and dry. Numerous spider angiomas on upper abdomen with several dilated veins across abdomen. Several ecchymoses on lower extremities.
VS: 120/60, 104, 32, 99.1° F (37.3° C), Spo2 90%. Ht. 74 in (188 cm); wt. 145 lb (65.8 kg).
9. What is the significance of the spider angiomas, dilated abdominal veins, peripheral edema, and distended abdomen?
10. How would you further assess the distended abdomen? What is the clinical name for and the significance of your findings?
11. In what position should you place D.G? Write a brief rationale for your response.
c. Right side-lying
d. Left lateral recumbent
12. What objective findings concern you about his nutritional assessment and why?
13. Why is D.G.’s breath musty?
.14. Which of D.G.’s assessment findings are consistent with hepatic encephalopathy?
15. Which assessment findings, if present, would indicate a deterioration of D.G.’s condition?
e. Frequent diarrhea
f. Nausea and vomiting
g. Increased urine output
h. Development of asterixis
16. What is asterixis?
CASE STUDY PROGRESS
3.4 mEq/L (3.4 mmol/L)
Alanine transaminase (ALT)
Aspartate transaminase (AST)
Alkaline phosphatase (ALP)
3.6 mg/dL (61.6 mcmol/L)
2.1 g/dL (3.0 mcmol/L)
5.3 g/dL (53 g/L)
155 mcg/dL (111.0 mcmol/L)
17. Interpret D.G.’s laboratory results.
18. You begin to develop D.G.’s care plan. It is imperative to prevent bleeding when caring for a person with cirrhosis. List 4 specific interventions you will take to reduce D.G.’s bleeding risk.
19. Falls are particularly dangerous for someone in his situation. Why?
20. What measures will you implement to promote optimal skin integrity?
21. You identify the nursing problem “excess fluid volume.” Which is the best short-term goal for D.G.? D.G. will:
i. Have a decrease in abdominal girth
j. Maintain his ordered fluid restriction
k. Select low-sodium foods from the diet menu
l. Have no further weight gain before discharge
22. Describe 5 interventions that will help improve D.G.’s nutritional status.
23. What interprofessional referrals might you initiate and why?
CASE STUDY OUTCOME
D.G. develops an upper GI bleed during his third hospital day. After 24 days, including a week in the intensive care unit, he is discharged to a rehabilitation facility. He had been employed as a loading dock worker; unfortunately, his health never recovers to the point where he can return to work.