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CRITICAL THINKING SUMMARY – 3/24/14
Student: Kimberly Gaffney
Client Dx: Hepatic encephalopathy Age: 72
Allergies: no known allergies
The MEDICAL DIAGNOSIS that brought the client to the hospital is:
Hepatic encephalopathy
PATHOPHYSIOLOGY of diagnosed disease: (From text)
Two major alterations occur with this disease. First hepatic insufficiency because of the inability of
the liver to detoxify toxic byproducts of the metabolism. Secondly the Portal –systemic shunting, in
which collateral vessels develop as a result of portal hypertension, allows elements of the portal
blood to enter systemic circulation (Smeltzer, Bare, Hinkel, & Cheever, 2010).
SYMPTOMS typically seen with this diagnosis include (as identified in your text):
The signs and symptoms of hepatic encephalopathy asterixis, fetor hepaticus, generalized slowing
of ECG, impaired writing and ability to draw figures, minor mental changes and motor
disturbances. Other presenting symptoms are confusion, altered mood and sleep pattern, increased
deep tendon reflexes, rigidity of extremities. If condition continues to progress it can result in coma
(Smeltzer et al., 2010).
CLIENT’S SYMPTOMS of the diagnosed disease include:
This patient was admitted to the hospital on 3/22/14 with increased abdomen distention, slow
speech and walking, difficulty remembering, lethargy, shortness of breath and disorientation.
While working with him on 3/24/14, the patient was presenting with jaundice, shortness of breath,
increased heart rate, low blood pressure, increased abdomen distention, weakness, lethargy, and an
unsteady gait.
NUTRITIONAL ASSESSMENT:
Height (actual or estimated): 182.88 cm, 72in
Weight (actual or estimated): 108kg, 238.09lbs
Estimate Ideal Body Weight (Male: 105lb + 6 lb/inch > 5’. Female: 100lb + 5lb/inch > 5’): 177lb
Does this client have characteristics of a well-nourished person? Yes __ No X
Explain your answer.
The patient has loss total of 15 lbs. in last two months without trying to lose weight. His total
protein level was 4.1 and albumin level was 1.46, these are low, which indicates the patient is
malnourished. Based on his physical assessment, he was weak in his lower extremities, had moist
skin and smooth nails. While caring for this patient he expressed that he would like to eat, this
indicated to me that he had a good appetite. Unfortunately he was on a clear liquid diet, but he
drank all the ice tea, water, Jell-O and broth he was given. His BMI s 32.3 which indicates he is
obese in terms of height to weight ratio.
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PSYCHOSOCIAL STAGE OF DEVELOPMENT
What is the client’s developmental stage?
Ego integrity versus despair
Has he/she met the necessary accomplishments? Yes X No __
Explain.
After meeting the patient for the first time he seemed tired and anxious but friendly. The patient is
retired and owns his own home. The ego integrity versus despair stage of psychosocial
development requires the older adult to look back on life with pride and no regrets with a positive
and enthusiastic attitude (Taylor, Lillis, LeMone & lynn, 2011). When speaking of his family, he
was positive, and proud of his children and grandchildren and in what they had accomplished.
How is this illness affecting the client’s ability to meet these necessary accomplishments?
The patient’s diagnosis is somewhat affecting his ability to meet the necessary accomplishments
because he is sick and frequently tired and has been in the hospital for a few days. As a result one
can see how these things may affect his ability to meet the necessary accomplishments related to
the ego integrity vs. despair stage. However at this point he is remaining optimistic and talks about
the past with both family and staff members who enter the room.
NURSING DIAGNOSIS/OBJECTIVES/INTERVENTIONS
Indicate below the 2 priority nursing diagnoses that are most relevant for your client.
#1 NURSING DIAGNOSIS (problem r/t)
Chronic pain r/t: liver enlargement
DEFINING CHARACTERISTICS (S/S) that support this diagnosis:
A patient with chronic pain experiences unpleasant sensory and emotional experiences rising from
actual or potential tissue damage (Ladwig & Ackley, 2014). The defining characteristics are
patients self –report of 8/10 on a numerical scale and grimacing with movement.
OBJECTIVE/CLIENT OUTCOME for this diagnosis:
The patient will report being pain free 0/10 using a numerical scale (Ladwig & Ackley, 2014).
NURSING INTERVENTIONS that will assist the client to resolve the above identified diagnosis:
1. Assess patient’s pain level, sedation level and respiratory status every four hours (Ladwig &
Ackley, 2014).
2. Administer analgesics as prescribed (Ladwig & Ackley, 2014).
3. Encourage the client to plan activities around periods of greatest comfort when possible (Ladwig
& Ackley, 2014).
#2 NURSING DIAGNOSIS (problem r/t)
Fatigue related to cirrhosis and malnutrition
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DEFINING CHARACTERISTICS (S/S) that support this diagnosis:
A patient with fatigue experiences an overwhelming, sustained sense of exhaustion and decreased
capacity for physical and mental work at usual level (Ladwig and Ackley, 2014).
Respiratory difficulties, disinterest in surroundings, increased drowsiness, increased physical
complaints, lethargy, and verbalization of a lack of energy are the defining characteristics
associated with fatigue.
OBJECTIVE/CLIENT OUTCOME for this diagnosis:
The client will be free of fatigue (Ladwig & Ackley, 2011).
NURSING INTERVENTIONS that will assist the client to resolve the above identified diagnosis:
1. Evaluate adequacy of nutrition and sleep hygiene: encourage adequate rest, limit naps in
afternoon and evening, limit caffeine in afternoon and evening, and use a routine sleep/wake
schedule (Ladwig & Ackley, 2014).
2. Collaborate with primary care provider to identify physiological and physiological causes of
fatigue: pain, electrolyte imbalance, depression, anemia, medication effects (Ladwig & Ackley,
2014).
3. Encourage client to try complementary and alternative therapy such as guided imagery, massage
therapy and acupressure (Ladwig & Ackley, 2014).
COMPLICATIONS:
If this client’s condition were to worsen, what would be the most likely reason and why?
If the client’s condition were to worsen, it would most likely be due bleeding or hemorrhage. With
damage done to the liver, the liver cells are not able to use vitamin K to make prothrombin resulting
in the gastrointestinal tracts inability to absorb all the vitamin K it is receiving, this results in a
decreased production of the clotting factors, with decreased clotting factors the patient is at a high
risk of bleeding (Smeltzer et al, 2010).
How would you know this is happening?
The nurse would know if bleeding was occurring if patient has symptoms of shortness of breath,
fatigue, pale mucous membranes, visual bleeding from nose, mouth or wounds, blood was found in
urine, sputum or stool, patient had unusual bruising, dizziness or altered level of consciousness and
possible if CBC , Hgb, Hct, are decreased. Also if vital signs or diagnostic tests results reflected
changes in patient condition (decreased blood pressure increased heart rate and respirations).
What will you do if this happens?
If this were to happen, the nurse would notify physician, monitor vital signs, if ordered administer
vitamin K, hold pressure to site if bleeding is visualized, and administer a blood transfusion. Also
monitor the patients’ (CBC, Hgb, Hct) levels for blood loss, effects of mediations administered and
an increase of yellowing of the skin.
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PHYSICIAN PRESCRIBED MEDICATIONS AND INTERVENTIONS
MEDS/IVs/TX/DIET
(Include dose, route,
frequency)
REASON
PRESCRIBED
(Drug Classification,
What is it treating?)
Buspirone 5mg/ 1tab p.o.
twice daily
Antianxiety agent/
management of anxiety
Hydroxyzine 25 mg 1 to 2
capsules
Antihistamine -pruritus
Ferrous sulfate 325 mg/1 tab
p.o. daily
Antianemic- GI
bleeding and hgb -7.4
Sodium chloride 0.9% at
100ml/hr
NURSING
IMPLICATIONS
FROM TEXT
(Checking for adverse
reactions, preparation
& administration
concerns)
Dizziness, nervousness,
weakness, blurred
vision sweating.
Drowsiness, ataxia, dry
mouth, wheezing,
urinary retention,
Dizziness, constipation,
dark stools, nausea,
headache. Administer 1
hour before or 2 hours
after meals.
Electrolyte replacement- Heart failure,
used for electrolyte and pulmonary edema,
fluid maintenance.
hypernatremia,
hypokalemia,
hypervolemia-
Norco
Opioid analgesic –pain
(acetaminophen/hydrocodone
10mg/325 1tab p.o.every
four hours as needed for
pain.
Respiratory depression,
hypotension,
bradycardia, confusion,
Piperacillin tazobactam
3.375Gm 50ml IVPB every 6
hours.
Seizures, confusion,
pseudomemebranous
colitis, diarrhea, and
pain at IV site.
Anti-infective/extended
spectrum penicillin- has
bacterial infection
CLIENT DATA
FROM YOUR
ASSESSMENT
(What data is
important to know
before & after giving)
Limit intake of grape
fruit juice it can
increase serum levels,
assess degree of anxiety
before and during
therapy.
Assess degree of itching
and skin involved.
Monitor for sedation, or
agitation.
Assess for constipation
and diarrhea, monitor
hgb and hct.
Monitor I&O, daily
weight, edema, lung
sounds, hypo and
hypernatremia,
tachycardia , dry
mucous membranes
Assess vital signs
before and during
administration, assess
bowel function. Assess
pain type, location and
intensity
Assess for infection
(v.s., urine, stool,
appearance of wounds).
Obtain culture and
sensitivity prior to
initiating first dose.
Observe for
anaphylaxis. Monitor
WBC, BUN, AST,
ALT, electrolytes and
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Rifaximin 20mg/ml oral
suspension 550mg (27.5ml)
p.o. twice daily
Anti-infective -reduce
risk of hepatic
encephalopathy
symptoms.
Dizziness, peripheral
edema and
pseudomembranous
colitis
Cholestyramine 4 Gm 1
packet p.o. daily
Bile acid sequestrant –
decreases
pruritus/jaundice
Abdominal discomfort,
constipation, nausea,
tongue irritation and
flatulence. Mix with 46oz of water, juice or
milk wait 1hour before
administration of other
medication.
Dilaudid 0.5 mg I.V. push
every 3 hours for pain
Opioid analgesiaabdomen pain
Confusion, dizziness,
sedation, hypotension,
constipation
hgb and hct.
Assess mental status,
monitor bowel function:
diarrhea, bloody stool,
fever, cramping.
Monitor lymphocytes,
monocytes and
neutrophils.
Assess severity of
itching and skin
integrity. Monitor AST,
ALT, phosphorous,
chloride, alkaline
phosphate, calcium,
sodium and potassium
and prothrombin time
levels.
Assess pulse, B.P. and
respirations and pain
before giving.
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Analysis of Diagnostic Tests
DIRECTIONS:
1.
List all diagnostic and laboratory tests pertinent to the patient's medical diagnosis or
medical treatments (i.e. medications) and provide the patient values for each test. Explain
why they are pertinent for this patient.
2.
List any screening diagnostic and laboratory tests that are not within normal limits.
Explain why these tests are increased or decreased in relation to your patient's medical
condition.
Diagnostic/Lab Test
sodium
Patient Values
134
Analysis of Values
Low- hepatic failure
potassium
5.4
High- CHF, acute renal injury
creatinine
1.91
High-acute renal injury
HCO3
19
Low- acute renal injury
Hgb
7.4
Low-anemia, cirrhosis,
Hct
22.0
Low-anemia, cirrhosis
MDRD GFR
35
Low-cirrhosis
Glucose level
100
cirrhosis
Albumin
1.4
Low- Jaundice, malnutrition,
cirrhosis
Total protein
4.1
Low- jaundice, cirrhosis
malnutrition
Bili total
15
High- jaundice, cirrhosis
Alk phosphate
156
High- jaundice, cirrhosis and
biliary obstruction
procalcitonin
8.91
High- Indicative of bacterial
infection and risk for sepsis.
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Urea Nitrogen
29
High- GI bleeding, decreased
renal perfusion
AST
93
High- jaundice, cirrhosis
ALT
37
High-cirrhosis, jaundice
Total calcium level
7.6
Low- hypoalbuminemia
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References
Smeltzer, S.C., Bare, B.G., Hinkle, J.L. & Cheever, K.H. (2010). Brunner & Suddarth’s
Textbook Medical -Surgical Nursing (12th ed.). Philadelphia, PA: Wolters Kluwer,
Lippincott Williams & Wilkins.
Ladwig, G. B. & Ackley, B.J. (2014). Guide to nursing diagnosis (4th ed.). Maryland Heights,
MO: Mosby.
Taylor, C., Lillis, C., LeMone, P., & Lynn, P. (2011). Fundamentals of Nursing: The Art and
Science of Nursing Care (7th ed.). Philadelphia, PA: Lippincott Williams & Wilkin.