NURSING 110 & 111 NURSING CARE PREPARATION
Student Name: Elizabeth Archibald Date of Care: 01/31/2017
Unit/Room Number: Med Surg 4-1 Date of Admission: 01/29/2017
Age: 06/30/1955 Ethnic/Cultural Preferences: Caucasian
Gender: Female Allergies: No known environmental/food
Eriksons Developmental Level: Ego allergies
integrity Med allergies: Pennicillin, Sulfas,
Chantix, Depakore, Effexor, Duragesic.
Code Status: Full Code
Primary Diagnosis: Acute Hepatic Encephalopathy (End Stage Liver Disease) /// Liver
Carcinoma
Co-morbidities: COPD, Emphysema, Asthma, Arthritis, DM2, Bipolar, Tobacco Use
Disorder, Cirrhosis, Chronic Pain, Opioid Dependence, Idiopathic Peripheral
Neuropathy, Portal HTN.
Discharge Plan (add day of clinical): Patient is being discharged today.
Patient is to continue to take Lactulose at home. Patient is to not drink ETOH, and not
smoke pot.
Integrated Pathophysiology:
Patient presented to the E.D. with her husband, and was intoxicated, extremely
disoriented, and aggressive.
Patient has a long history of Liver carcinoma, and is in end stage liver disease.
Lab values showed that patient had an Ammonia level of 125 umol/L,
and head CT shows that there is mild cerebral atrophy. Head CT does not show a
bleed.
Chest rads show minimal bibasal atelectasis, but otherwise WNL.
Patient had elevated Chloride, and RDW; and lowered BUN, CREA, ABL, WBC, HCT,
Platelets.
(See levels and explanations below).
Patient has co-morbitities, including: COPD, Emphysema, Asthma, Arthritis, DM2,
Bipolar, Tobacco Use Disorder, Cirrhosis, Chronic Pain, Opioid Dependence, Idiopathic
Peripheral Neuropathy, and Portal HTN.
Patient has the following medications: Busparone 10 MG PO TID for anxiety,
Spirolactone 25 MG PO QD to reduce fluid load, Gabapentin 100 MG PO TID to treat
nerve pain, Risperidone 0.5 MG PO BID as a mood stabilizer, Lactulose 30 MG PO QID
to help pass ammonia, and NF- Rifaximin 550 MG PO BID to decrease hepatic
encephalopathy.
Patients primary diagnosis = Acute Hepatic Encephalopathy (End Stage Liver Disease)
R/T Liver Carcinoma.
Patient has a history of Hepatitis C, and Hepatic Carcinoma that have contributed to
liver failure.
This disease is characterized by confusion, and altered mental state secondary to liver
disease.
The livers main function is to filter the blood and expel poisons.
When the liver is not functioning properly, the body is unable to excrete potentially toxic
substance, such as ammonia. These toxins build in the blood and create
encephalopathy.
Data Collection
Diet (Type): Regular IV (Fluid type, rate, access type): 0.9% NS @
100 ML/HR
I&O (MD order/Nursing Order/Frequency): CBG (Yes/No, frequency): Yes, before
Monitored BID meals.
Fall Risk/Safety Precautions (Yes/No): No Activity (What is ordered): Normal
Wound Care (Yes/No): No Oxygen (Yes/No, Delivery method, how much):
None
Drains (Yes/No, Type): No Last BM: This AM 1/31 pt. had a normal
BM.
Other Tubes: None
ASSESSMENTS
(Include Subjective & Objective Data)
Integumentary: Head and Neck:
Patients skin is intact. She does not Patient has a symmetrical face and head.
have any masses, lesions, or abrasions. There are no masses, lesions, abrasions,
pediculitis, or xerosis present.
Tips of fingers and toes are red.
Hair is thick, and does not appear to be
Distal legs are dry, and scaly with xerosis alopecic.
present.
Skin is warm to the touch,
and skin turgor does not tent.
Patient has many bruises where the staff
attempted to get a viable IVC. Patient
has very friable veins.
Many scars present on arms due to
previous drug abuse.
Eyes/Ear/Nose/Throat: Thorax/Lungs:
Eyes are anicteric, and PERRLA. Thorax and Lungs are normal.
Patient has not experienced any vision No murmur, or arrhythmias auscultates in
changes R/T DM 2. the heart.
No crackles, wheezes, or rhonchi
Ears are clean, and are not giving patient auscultated in the lungs.
any trouble.
She is not experiencing any hearing loss.
Nose is clear of discharge, and both
nares are patent.
Trachea is midline. Patient does not
have trouble swallowing.
Patient has natural teeth on top, but no
teeth on the bottom.
Gingiva is anicteric.
Eyes/Ear/Nose/Throat: Thorax/Lungs:
Eyes are anicteric, and PERRLA. Thorax and Lungs are normal.
Patient has not experienced any vision No murmur, or arrhythmias auscultates in
changes R/T DM 2. the heart.
No crackles, wheezes, or rhonchi
Ears are clean, and are not giving patient auscultated in the lungs.
any trouble.
She is not experiencing any hearing loss.
Nose is clear of discharge, and both
nares are patent.
Trachea is midline. Patient does not
have trouble swallowing.
Patient has natural teeth on top, but no
teeth on the bottom.
Gingiva is anicteric.
Cardiac: Musculoskeletal:
Diminished pulses to left posterior tibial No pain. Patient reports a 0/10 pain
pulse. scale.
(1+). Bilateral pedal pulses are bounding Patient is fully ambulatory.
(3+).
Assessment verified with Doppler.
Patient does not report any peripheral
neuropathy, or calf pain.
Patient does not present with any edema.
CRT is hard to assess in all four limbs
due to fungal infestation.
Cardiac: Musculoskeletal:
Diminished pulses to left posterior tibial No pain. Patient reports a 0/10 pain
pulse. scale.
(1+). Bilateral pedal pulses are bounding Patient is fully ambulatory.
(3+).
Assessment verified with Doppler.
Patient does not report any peripheral
neuropathy, or calf pain.
Patient does not present with any edema.
CRT is hard to assess in all four limbs
due to fungal infestation.
Genitourinary: Gastrointestinal:
Patient has normal urination. Patient had a normal BM this AM. She is
She had a urinary foley catheter upon on Lactulose to pass excess ammonia,
admittance, but this had been and not to encourage fecal passage.
discontinued now.
Neurological: Other (Include vital signs, weight):
Patient is A/O X 4. T- 98.1 F
She constantly twitches her feet, and P- 78 BPM
moves her bottom jaw. R- 16 BPM
Patient is in a good mood, and does not BP- 115/61
report any dizziness.
Pain- 0/10
SPO2- 90%
Neurological: Other (Include vital signs, weight):
Patient is A/O X 4. T- 98.1 F
She constantly twitches her feet, and P- 78 BPM
moves her bottom jaw. R- 16 BPM
Patient is in a good mood, and does not BP- 115/61
report any dizziness.
Pain- 0/10
SPO2- 90%
CURRENT MEDICATIONS
List ALL regularly scheduled and prn medications scheduled on your client.
(Due morning of clinical)
Generic Classific Dose/ Onset/ Expected Adverse Nursing Intervention for this
Name ation Route/ Peak outcome reaction client. (consider expected
& Trade Rate if IV (One outcome and adverse
Name common reaction)
adverse
reaction)
S Furose Loop 20 mg 2-10 Increase fluid Fluid Monitor intake
a mide
Diuretic IV minutes output volume and output
m Lasix
p
deficit Monitor for signs/
l symptoms of
e dehydration
Anti- 10 MG 7-10 Decrease Dizziness Assess for tolerance or
buspiron Anxiety PO TID days (O) anxiety impaired control.
e 3-4
(Buspar) weeks
(P)
K- 25 MG Unknow Decrease BP Confusion Assess for hypokalemia
spirolact Sparing PO QD n (O) (weakness/fatigue/PUPD)
one diuretic 1-2 H (P)
(Aldacto
ne)
gabapen Analge 100 MG Rapid Decreased Confusion Monitor for note able
tin sic PO TID (O) Nerve Pain changes in behavior.
(Neuroti Mood 2-4 H (P)
n) Stabiliz
er
risperido Anti 0.5 MG 1-2 Decreased S/ Aggressive Monitor for note able
ne psychot PO BID weeks S Behavior changes in behavior.
(Risperd ic (O) Of bipolar
al) mood Unknow disorder
stabiliz n (P)
er
laxative 30 GM 24-48 H Help body to Cramps Assess BMs to rule out
lactulos PO QID (O) eliminate diarrhea.
e Unknow Ammonia.
(Cephul n (P)
ne)
gabapen Analge 100 MG Rapid Decreased Confusion Monitor for note able
tin sic PO TID (O) Nerve Pain changes in behavior.
(Neuroti Mood 2-4 H (P)
n) Stabiliz
er
risperido Anti 0.5 MG 1-2 Decreased S/ Aggressive Monitor for note able
ne psychot PO BID weeks S Behavior changes in behavior.
(Risperd ic (O) Of bipolar
al) mood Unknow disorder
stabiliz n (P)
er
laxative 30 GM 24-48 H Help body to Cramps Assess BMs to rule out
lactulos PO QID (O) eliminate diarrhea.
e Unknow Ammonia.
(Cephul n (P)
ac)
Anti- 550 MG Unknow Decrease Peripheral Listen to bowel sounds.
NF- infectiv PO BID n (O) Hepatic Edema Monitor stool for
rifoximin e Unknow Encephalopa consistency.
(xifaxan) n (P) thy
DIAGNOSTIC TESTING
Include pertinent labs [ABGs, INRs, cultures, etc] & other diagnostic reports [X-rays, CT, MRI, U/S,
etc.]
NOTE: Adult values indicated. If client is newborn or elder, normal value range may be
different.
Date Lab Test Patient Values/ Interpretation as related to patients
Normal Values Date of care diagnosis cite reference & pg #
1/31 Sodium 139
135 145 mEq/L
1/31 Potassium 3.5
3.5 5.0 mEq/L
1/31 Chloride 109 High --- R/T disturbed kidney values
97-107 mEq/L
1/31 Co2 25
23-29 mEq/L
1/31 Glucose 106
75 110 mg/dL
1/31 BUN 5 Low --- Kidney function can be altered
8-21 mg/dL
by cirrhosis.
1/31 Creatinine 0.46 Low --- Kidney function can be altered
0.5 1.2 mg/dL
by cirrhosis.
1/31 Uric Acid Plasma -
4.4-7.6 mg/dL
1/31 Calcium 8.1
8.2-10.2 mg/dL
1/31 Phosphorus -
2.5-4.5 mg/dL
1/31 Total Bilirubin 2.3
0.3-1.2 mg/dL
1/31 Total Protein 6.6
6.0-8.0 gm/dL
1/31 Albumin 3.0 Low --- R/T liver disease
3.4-4.8gm/dL
1/31 Cholesterol -
by cirrhosis.
1/31 Uric Acid Plasma -
4.4-7.6 mg/dL
1/31 Calcium 8.1
8.2-10.2 mg/dL
1/31 Phosphorus -
2.5-4.5 mg/dL
1/31 Total Bilirubin 2.3
0.3-1.2 mg/dL
1/31 Total Protein 6.6
6.0-8.0 gm/dL
1/31 Albumin 3.0 Low --- R/T liver disease
3.4-4.8gm/dL
1/31 Cholesterol -
<200-240 mg/dL
1/31 Alk Phos 60
25-142 IU/L
1/31 SGOT or AST 20
10 48 IU/L
1/31 LDH -
70-185 IU/L
1/31 CPK -
38-174 IU/L
1/31 WBC 2.6 Low --- Portal hypertension may cause
4.5 11.0
the spleen to enlarge and retainwhite
blood cellsand platelets, reducing the
numbers of these cells and platelets in
the blood. Alowplatelet count may be
the first evidence that a person has
developedcirrhosis. Metabolic
bonediseases.
1/31 RBC 4.7
male: 4.7-5.14 x 10
female: 4.2-4.87 x
10
1/31 HGB 12.5
male: 12.6-17.4 g/
dL
female: 11.7-16.1 g/
dL
1/31 HCT 36.6 Low --- R/T anemia/low platelets
male: 43-49%
female: 38-44%
1/31 MCV 85.7
85-95 fL
1/31 MCH 29.3
28 32 Pg
1/31 MCHC 34.2
33-35 g/dL
1/31 RDW 15.6 High --- R/T anemia/low platelets
11.6-14.8%
1/31 Platelet 37 Low --- R/T kidney dysfuntion.
150-450
Low --- Portal hypertension may cause
the spleen to enlarge and retainwhite
blood cellsand platelets, reducing the
numbers of these cells and platelets in
the blood. Alowplatelet count may be
the first evidence that a person has
developedcirrhosis. Metabolic
bonediseases.
85-95 fL
1/31 MCH 29.3
28 32 Pg
1/31 MCHC 34.2
33-35 g/dL
1/31 RDW 15.6 High --- R/T anemia/low platelets
11.6-14.8%
1/31 Platelet 37 Low --- R/T kidney dysfuntion.
150-450
Low --- Portal hypertension may cause
the spleen to enlarge and retainwhite
blood cellsand platelets, reducing the
numbers of these cells and platelets in
the blood. Alowplatelet count may be
the first evidence that a person has
developedcirrhosis. Metabolic
bonediseases.
DIAGNOSTIC TESTING
Date UA Interpretation as related to
Normal
Results Pathophysiology cite
Range reference & pg #
Color/
Appearance
pH
Spec Gravity
Protein
Glucose
Ketones
Blood
Date Other Interpretation as related to
(PT, PTT, INR, Normal Pathophysiology cite
Results
ABGs, Cultures, Range reference & pg #
etc)
1/31 Manual diff NEG NEG
1/31 Ammonia 16-53 81 umol/L R/T liver disease-
umol/L Body is unable to filter.
1/31 GFR >60 ml/L
1/30 SGPT/ALT 7-52iu/L 9
1/30 Ammonia 16-53 125 R/T liver disease-
umol/L Body is unable to filter.
1/30 CGH-PT 9.3-11.4 13.1
1/30 CGH-INR 0.9-1.2 1.29 R/T liver disease---
INRis related to the
prothrombin time (PT). If
there is seriousliver
diseaseandcirrhosis,
thelivermay not produce the
normal amount of proteins
and then the blood is not
able to clot normally.
Date Interpretation as related to
Pathophysiology cite
1/31 GFR >60 ml/L
1/30 SGPT/ALT 7-52iu/L 9
1/30 Ammonia 16-53 125 R/T liver disease-
umol/L Body is unable to filter.
1/30 CGH-PT 9.3-11.4 13.1
1/30 CGH-INR 0.9-1.2 1.29 R/T liver disease---
INRis related to the
prothrombin time (PT). If
there is seriousliver
diseaseandcirrhosis,
thelivermay not produce the
normal amount of proteins
and then the blood is not
able to clot normally.
Date Interpretation as related to
Radiology Results Pathophysiology cite
reference & pg #
9/28 X-Rays Minimal Bibasal
Atelectasis
Otherwise WNL
9/28 Scans Head CT- Mild
cerebellar atrophy,
otherwise WNL.
EKG-12 lead
Telemetry
DAR NURSING PROGRESS NOTE
1/31/17 @ 10 AM
Priority Diagnosis: Liver Failure // Hepatic Encephalopathy
D: Decreased left posterior tibial and pedal pulse palpated. Doppler confirms
depression to left lower limb.
No erythema, warmth, pain present. Skin dry and flakey.
A: Educated patient on cause of decreased pulses and what to do at home to prevent
this.
R: Patient is to elevate legs, warm soak feet, utilized a heating pad, and use a lot of
lotion to both lower limbs.
S: Liz, RN student.
1/31/17 @ 11 AM
Priority Diagnosis: Liver Failure /// Hepatic Encephalopathy
D: Patient is anxious to leave the hospital to have a cigarette,
but we are still waiting on discharge instructions.
A: Student nurse approaches patient and informs her that it will be a little longer until
she can leave,
And offered to get patient a warm blanket and some coffee for the time being.
R: Patient is okay with this, and gets comfortable.
S: Liz, RN student.
1/31/17 @ 11:30 AM
Priority Diagnosis: Liver Failure /// Hepatic Encephalopathy
D: Patient being discharged.
A: Pulled IVC, help pressure for 1-3 minutes, then wrapped.
Site where IVC was placed was not red, edemic, or painful. Patient did not complain of
discomfort.
R: Patient is to remove bandage when she gets home.
S: Liz, RN student
PATIENT CARE PLAN
Patient Information (Include data to support selected nursing diagnostic statement):
See Above
Nursing Diagnosis should include Nanda Nursing Diagnostic statement, related to (R/T), as evidenced by
(AEB).
Problem #1 Risk for disrupted skin integrity R/T decreased peripheral pulses AEB
palpation of peripheral arteries bilaterally, and confirmation with Doppler.
Desired Outcome: Patient will avoid skin ulcers and ischemia.
Nursing Interventions Client Response to Intervention
1. 1.
Patient is to soak her feet/lower legs in
warm water to promote circulation.
2. Patient is to elevate feet as often as 2.
possible to promote venous return to
heart.
Problem #1 Risk for disrupted skin integrity R/T decreased peripheral pulses AEB
palpation of peripheral arteries bilaterally, and confirmation with Doppler.
Desired Outcome: Patient will avoid skin ulcers and ischemia.
Nursing Interventions Client Response to Intervention
1. 1.
Patient is to soak her feet/lower legs in
warm water to promote circulation.
2. Patient is to elevate feet as often as 2.
possible to promote venous return to
heart.
3. Patient is to apply lotion to lower legs 3.
and feet to maintain skin integrity.
4. Patient is still ambulatory. She is to 4.
stay active to avoid blood stasis.
Evaluation (evaluate goal & interventions, what worked/what didnt, what would you adapt if
needed):
Did not have the adequate time to assess patient response, and evaluate.
Problem #2 Risk for altered mental state R/T drinking, and inability to filter toxins,
AEB laboratory proof of ammonia build up in blood, and CT proof of encephalopathy.
Desired Outcome: Patient will maintain the cognition that she has left to avoid times
of confusion.
Nursing Interventions Client Response to Intervention
1. Patient is to continue to utilize 1.
Lactulose at home to pass excessive
ammonia.
2. Patient is to avoid ETOH and 2.
marijuana at all times.
3. Patient is to stay hydrated, by 3.
drinking at least 9-10, 8 fluid ounce
glasses of water per day.
4. Patient is to maintain a healthy diet 4.
with balance vitamins and minerals.
Evaluation (evaluate goal & interventions, what worked/what didnt, what would you adapt if
needed):
Did not have the adequate time to assess patient response, and evaluate.
