CASE STUDY
ON
DECOMPENSATED CHRONIC LIVER
DISEASE (DCLD)
SUBMITTED TO: SUBMITTED BY:
Mrs JHUNILATA PRADHAN (Mam) RAM NINAD PATTNAIK
ASST.PROFESSOR MSC NURSING 2ND YEAR
SUM NURSING COLLEGE SUM NURSING COLLEGE
SUBMITTED ON:
IDENTIFICATION DATA
Client’s name : Mr. Sishir kumar muduli
Age : 52 years
Sex : Male
IP No : 9337120875
Date of admission : 28.7.24 at 11.10 am
Ward : ward -18
Bed no. : 24
Education : 10 th
Occupation : worker
Marital status : Married
Religion : Hinduism
Address : Nayagarh
Provisional diagnosis: Decompensated chronic liver disease.
I. Presenting Chief Complaints:
The patient complaints for –
Vomiting for 2 days
Altered behavior for 2 days
Abdominal pain for 2 days
II. History of Present Illness
Mr. sisir ku muduli received at emergency department IMS & SUM Hospital due to
vomiting and altered behavior on date 28.07.24 .my patient shifted to gastro icu at 7.50pm
28.7.24 then he came to ward 18 for further management.
III.Past medical history
Mr. sisir ku muduli not having any past medical history.
IV. Past surgical History
Mr. sisir ku muduli not having any past surgical history
V. Family History
No. of Family Members : 06
History of Any Chronic illness : Mr. sisir ku muduli mother was history of
hypertension .
Any communicable Disease in Family : No significant history of any communicable disease.
Any Congenital Disease in Family : No specific congenital disease is found .
Any Hereditary Disease in Family : No specific hereditary disease is found
Any Disability in the Family : No specific disabilities is found
VI. Family characteristics-
Mr. sisir ku muduli lives in extended family.
Socioeconomic history:
Mr sisir ku gouda is the head of family.
He belongs to a middleclass family.
He is a industrial worker.
Electricity and water facilities are available in house.
Drainage facility is proper.
Income per month: The monthly income is approx. 25,000/-.
Expenditure: approx.: 15,000 /- rupees
Recreational facilities: Present
Medical facilities: Available
Personal History:
Habits & hobbies: He drinking alcohol since 9 years and
His hobbies is spending time with his family
Elimination pattern:
Bladder elimination: He passed urine 5 -6 times in a day
Bowel elimination:- He passed stool since admission
Sleeping pattern: Sleeping pattern is good 7hrs per day
Nutritional history :
Vegetarian / non-vegetarian: Non-vegetarian
Likes / dislikes: He likes all kinds of vegetables &fish.
Any change in the dietary pattern: Avoidance of irritant foods, fried, vegetables, fast
food and balance diet is advice.
Vital Signs:
S.NO Vital Sign Normal Value Patient’s Value
1. Temperature 98.6 F 97.6 F
2. Pulse 60 – 100 Beats/M 92 Beats/M
3. Respiration 14 – 20 Breath/M 22 Breath/M
4. Blood Pressure 120/80 mmHg 124/86 mmHg
Visual Analogue Scale: The pain score of my patient is (4 – 5) and the pain is radiating from
left upper limb to left lower limb.
PHYSICAL EXAMINATION
1. GENERAL APPEARANCE
LEVEL OF CONSCIOUSNESS: Conscious and response to all my questions
ORIENTATION: Oriented to time and person and oriented to place
SKIN COLOUR: Brown
MOOD: Alert
ACTIVITY: Active but doctor order to take bed rest
BODY BUILD: Thin
NOURISHMENT: Well nourished
SPEECH : Clear
2. ANTHROPOMETRIC MEASUREMENT
WEIGHT: 71 kg
HEIGHT: 157 cm
3. HEAD TO FOOT EXAMINATION
I. HEAD
SHAPE :Normocephalic
SCALP :Clean
HAIR : My patient having black hair and distributed all over the
scalp.
FACE :My patient doesn’t have any puffiness or swelling in face.
SUBJECTIVE SYMPTOMS :No complaints
II. EYES
EYE BROWS :Hair are equally distributed and both eyes brows are
symmetric
EYE LASHES : Eye lashes are clean and equally distributed
EYE LIDS :Normal
PUPILLARY REFLEX :Reacting to light
PUPIL SIZE :Round
SCLERA :White
CONJUNCTIVA :Normal
CORNEAL REFLEX :Present
VISION :Normal
EYE MOVEMENT :Conjugate eye movement
USE OF GLASSES/CONTACT LENSES :My patient is not using any
type of glasses/ contact lens.
SUBJECTIVE SYMPTOMS :No complaints
III. EARS
USE OF HEARING AIDS :No
EAR CANAL :Both the canals are clean
TYMPANIC MEMBRANE :Normal
HEARING :Weber test is done and my patient can hear in both the ears
SUBJECTIVE SYMPTOMS :No complaint
IV. NOSE
EXTERNAL NOSE :Normal in shape and symmetry in size
NASAL SEPTUM :Central
NASAL POLYPS :Absent
NASAL MUCOSA : There is no swelling, bleeding or any discharge
FRONTAL & MAXILLARY SINUSES :Normal
SMELL SENTATION :Present
SUBJECTIVE SYMPTOMS :No complaint
V. MOUTH & THROAT
LIPS :No redness and swelling and lip is symmetry
TEETH :Dentures
GUMS : No bleeding is present
TONGUE :Clean, moist all around tongue without any redness
UVULA :No tenderness or redness
TASTE :Normal taste present
BAD ODOUR :Present
TONSIL :Enlargement is not present
VOICE :Clear
SUBJECTIVE SYMPTOMS :No complaint
VI. NECK
NECK :No mass is present
RANGE OF MOTION :Possible
THYROID GLAND :Not enlarged
JUGULAR VEIN :Not distended
TRACHEA :Midline
SUBJECTIVE SYMPTOMS :No complaints
VII. THORAX AND LUNGS
THORAX :Symmetrical
THORAX EXPANSION :Normal & Equal
BREATH SOUND:22 breath/min
COUGH :Absent
SPUTUM :Absent
SUBJECTIVE SYMPTOM :No complaints
VIII. HEART
HEART SOUND :S1 & S2 sound is present but S3 & S4 is absent
APICAL PULSE :present
PERIPHERIAL PULSE :82 beat/min
ARTIFICIAL PACEMAKER : Absent
OXEYGEN SUPPORT :Oxygen supplements is not given
SUBJECTIVE SYMPTOMS :absent
IX. GASTROINTESTINAL SYSTEM
MOUTH : Clean
TEETH :Clean
TONGUE :Clean
ORAL ULCER :Absent
ABDOMEN : swelling
PERISTALSIS :Present
NUTITIONAL ROUTE :Oral feeding
BOWEL MOVEMENT :Present
APPETITE :absent
PERCUSSION :Presence of Air
INGUINAL LYMPH NODE :No nodes are present
LIVER :Fatty liver
SPLEEN : Normal in size
KIDENY :abnormal in size
BOWEL SOUND: Present
PERIANAL SKIN INTEGRITY :Intact
SUBJECTIVE SYMPTOMS : pain in abdomen
X. GENITOURINARY SYSTEM
URINATION :normal
URINE: No sediments are present
GENITALIA: No discharge or edema is present
SUBJECTIVE SYMPTOMS : No complaints
XI. INTEGUMENTARY SYSTEM
SKIN :Intact
COLOUR : Brown
TEXTURE : Normal
TURGOR :Normal
HYDRATION :Good
TEMPERATURE : 96.3F
DISCOLOURATION :Absent
CYANOSIS :Absent
PERIPHERIES :Warm
ICTERUS :Absent
LESIONS/MASSES :No lesions/ masses are present
SUBJECTIVE SYMPTOMS :No complaint
XII. MUSCULOSKELETAL SYSTEM
POSTURAL CURVES :Normal
MUSCLE TONE :Normal
UPPER EXTRIMITIES
SYMMETRY :Upper extremities are symmetrical
MUSCLE STENGTH :Weakness
RANGE OF MOTION : Possible
BICEPS REFLEX :Normal
TRICEPS REFLEX :Normal
OEDEMA :Absent
JOINTS :NO complaint
DEFORMITY : Absent
LOWER EXTERMITIES
SYMMETRY : Lower extremities are symmetrical
MUSCLE STRENGTH : loose
RANGE OF MOTION :Possible
OEDEMA :Absent
JOINTS :No Tenderness
DEFORMITY :Absent
GAIT :Normal
VARICOSE VEINS :Absent
DEPENDENCY LEVEL :Partially dependent
SUBJECTIVE SYMPTOMS :Pain in left side upper limb to right
lower limb
CHRONIC KIDNEY DISEASE
INTRODUCTION
Introduction Decompensated chronic liver disease (DCLD) is a medical emergency with high
mortality, usually managed by non-specialists in emergency (ED) and acute medical (AMU)
departments in critical early stages.
DEFINITION
Decompensated chronic liver disease is defined as an acute deterioration in liver function in a
patient with cirrhosis.
ETIOLOGY-
L.NO ACCORDING TO BOOK ACCORDING TO
PATIENT
1 viral hepatitis (hepatitis B and hepatitis C)
2. alcohol-related liver disease. Alcohol related liver disease
3. Non alcoholic fatty liver disease
RISK FACTORS Disease- DCLD
NON MODIFIABLE-
Age alcohol
Diabetes
Gender
MODIFIABLE
Alcohol
Obesity
Viral hepatitis
PATHOPHYSIOLOGY
CLINICAL MANIFESTATION OF CHRONIC KIDNEY DISEASE
SL.NO ACCORDING TO BOOK ACCORDING TO
PATIENT
1 Peripheral edema. Nausea and vomiting
Nausea and vomiting. pain and fever
Constipation & diarrhea.
Pain and fever. an enlarged liver
Clubbing.
An enlarged liver or spleen. ascites
Ascites.
Red spider-like blood vessels on the skin
Jaundice.
DIAGNOSTIC EVALUATION (ACCORDING TO BOOK)
CBC
Liver biopsy
Ultrasound
endoscopy
hepatitis B and C
CT scan
MRI
ACCORDING TO PATIENT
History was collected and known that my patient having the history of liver disease
Computed tomography scan done.
CBC blood test done
SL.N INVESTIGATION PATIENT’S NORMAL UNIT
O VALUE VALUE
1. Complete blood
count
Blood studies
Haemoglobin 10.8 (13.0-17.0) gm/dl
Total Red blood 2.41 (4.5-5.9) 10^6/ul
cell count
PCV 21.8 (36.0-52.0) %
MCV 90.5 (81.0-97.0) fl
MCH 27 (26.0-34.0) pg
Platelets 133 (150-400) 10^3/ul
Total WBC 11.69 (4-10) 10^3/ul
different count 10.65 10^3/ul
Neutrophil 0.5 (40-80) 10^3/ul
Lymphocytes 0.01 (20-40) 10^3/ul
Eosinophil 0 (1-6) %
Monocytes 4.5 (2-10) %
Basophils 0.1 (<1-2) %
ESR
Routine
2. Investigation
RBS
Hba1c
Blood urea 47 Mg/dl
S. creatinine 8.43 Mg/dl
S. sodium 135 mEq/l
S. potassium 6.5 mEq/l
S. Chloride
PT control
INR
3. ABG
PH 7.271 7.350-7.450
PCO2 29.8 35.0-45.0 mmhg
PO2 184 80.0-100 mmhg
4. Urine test (on
14.01.2023)
Colour
Appearance
Pus cell L yellow 01
PH
Specific gravity 0.0 0-5 /HPF
Sugar
Protein
Epithet cell 0.1 2-5 /hpf
5. LFT
Bilirubin(T) 0.76 <2.0 Mg/dl
Bilirubin(D) 0.32 (0.1-0.4) Mg/dl
SGPT 5.4 (5-40) Iu/l
Alkaline phosphate 51.00 (5-40) Iu/l
Protein 5.5 (6-8.3) gm/dl
Albumin 2.6 3.3-5.2 gm/dl
Globulin 2.9 2.5-3.5 gm/dl
BLOOD GROUPING-B positive
Rh typing-Positive
COMPLICATION-
SL NO ACCORDING TO BOOK ACCORDING TO
PATIENT
1 Ascites
2 Hepatic encephalopathy Ascites
3 Spontaneous bacterial peritonitis
4 Hepato pulmonary syndrome
5 Hepato cellular carcinoma
MANAGEMENT
1 ACCORDING TO BOOK ACCORDING TO
Non pharmacological measure- PATIENT
balance diet Daily weighting
lifestyle modification Strict intake output
fluid restriction chart.
weight management Fluid intake
Pharmacological management- 1.0lit/day,
2. Diuretic therapy prevents volume INJ PIPTAZ 4.5
overload in CLD who can still produce GM TDS
urine
INJ PAN 40 MG
ANTIBIOTIC FOR INFECTION BD
INJ ALBUCEL LS
Surgical management- TAB RIFAGUT
3. Paracentesis 550 MG OD
Liver transplant TAB URSOCOL -
450 MG OD
NUTRITIONAL PLAN-
Calories- 35kcal /day/kg body weight
Protein- 0.6-0.8/kg/bodyweight
Fibers-30-35gms
Carbohydrate-Na
Fluids- 1.0lit/day
APPLICATON OF VERGINIA HENDERSON’S NEED THEORY IN NURSING
PROCESS-
Henderson was born on 30thNovember, 1897 in Kansas City, Missouri and dies on 17th march
1996.
She called as “the Nightingale of modern nursing”, “Modern -day mother of nursing”
She earned her Diploma in nursing from the army school of nursing in 1921, Bsc .in 1932, M.A
in 1934.
She worked as a teaching nursing in 1923, member of faculty. And research associate.
She was honored at the annual meeting of the nursing and allied health section on the medical
library association.
She created basic nursing curriculum for nursing in 1937
She developed the theory in 1950 -1970.
She proposed 14 components of basic nursing care.
Breathe normally
Eat and drink adequately.
Eliminate body waste
Move and maintain desirable posture
sleep and maintain desirable posture
sleep and rest
select suitable clothes-dress and undress
Maintain body temperature within normal range
Keep body clean and well groomed and protect from injury.
Avoid dangers in the environment and avoid injuries others
Communicating with others in expressing feeling
worship according to one’s faith
work in such a way that there is a sense of accomplishment
Play and participate in various forms of recreation, learn, discover, or satisfy the curiosity
that leads to normal development.
Nursing care plan :( By q application of nursing theory)
ASSESSMENT
Breathing: respiratory rate -24/min, maintained spo2 normal.
- patient had abdominal pain
- eating -advised fluid intake was 1000ml/day
- Eat inadequate diet,
- Moving: Able to move self in bed without support.
- Dressing and undressing appropriately: he was dressed with assistance.
- Communication: he was able to express self clearly. Hear and saw clearly.
NURSING DIAGNOSIS:
Excessive fluid volume related to decrease urine output as evidenced by edema.
Ineffective Breathing pattern related to chronic airflow limitation.
Imbalanced Nutrition less than body requirements related to anorexia or malabsorption
Anxiety related to change in health status as evidenced by insomnia and irritability.
Self-care deficit related to fatigue and weakness.
ASSESSM NURSING GOAL PLANNING IMPLEMENT RATIONAL EVALUATIO
ENT DIAGNOSI ATION E N
Based on S
Virginia
Henderson
’s Theory
Excessive He will -monitor the -monitored the -to prevent Client had a
He having fluid manifest fluid volume fluid volume fluid balanced fluid
decreased volume stabilize status of the status of the overload volume status
urine related to fluid client with I/o client with I/o as evidenced
output that decrease volume , chart. chart. by
he had urine output stable -monitor the -monitor the -To identify maintenance of
swelling as weight weight of the weight of the the fluid acceptable
abdomen evidenced and free client daily. client daily. volume bodyweight
by edema. from -advice salt -adviced salt and status
signs of and protein protein restricted -to control
edema. restricted diet. diet. edema
-monitor for -monitored for
signs of signs of -to indicate
pulmonary pulmonary the excess
edema like edema like fluid volume
shortness of shortness of status.
breath and breath and
tachypnea . tachypnea . - to remove
-administer -administered excess fluid
diuretic diuretic therapy from the
therapy as as prescribed. body
prescribed.
She started Ineffective Improve Assesse blood -Assessed blood To know Breathing
that he was Breathing ment of gases for gases for signs of client pattern
unable to pattern airway signs of hypoxaemia or condition maintain
sleep due related to clearanc hypoxaemia co2 To improve normal.
to chronic e and or co2 self activity
abdominal airflow achieve -Provided for
discomfort limitation. ment of -Provide for adequate -To relieve
a patent adequate ventilation and breathing
airway. ventilation gas exchange. problem.
and gas
exchange. -Maintained -To feel
open airway comfort.
ng -Maintaine
e open airway -Provided semi- -To relief
fowler position dyspnoea.
-Provide
semi-fowler -Provided
position oxygen therapy
-Provide
oxygen
therapy
Patient Anxiety To Assess -Assessed To relive Anxiety
having related to reduce client’s client’s stress reduced some
stress and change in stress behavioural behavioural extent.
worried health status level response. response. -to promote
about as sleep
disease. evidenced -Encourage -Encouraged the
Anxiety by insomnia the several several rest
and and rest periods periods during
insomnia irritability during the day the day
-Increase total -Increased total
hour night hour night sleep
sleep
-Encouraged use
-Encourage relaxation
use relaxation techniques
techniques mental
mental imaginary.
imaginary.
-Assesse for -Assessed for
sources of sources of
discomfort discomfort.
Dressing Self care To assist Assist his on Assisted his on he will feel he will feel
and un deficit his in bed in bed in cleaning better. better.
dressing related to meeting cleaning his his mouth ,whole
appropriate fatigue and her daily mouth ,whole body sponging,
ly. weakness. activitie body done, hair
he was s. sponging, combed, and
dressed done, hair dressed his.
with combed, and
assistance. dressed his.
HEALTH EDUCATION-
DIET-
- Advice for take balance diet
- Instruct for take 1 lit water per day more water can cause edema
- Advice for maintain a healthy weight
- Teach avoid alcohol, tobacco and smoked food to maintain effects of medication.
- Teach maintain about input and output chart, vital signs and weight regularly.
Management of disease condition
- Teach the patient and family members about cause ,effects, treatment, prognosis and
complication of decompensated chronic liver disease.
- Teach the patient to recognize and report complication like shortness of breath ,pain ,
swelling of abdomen, and vomiting.
- Advice to take balance diet.
- Advice the family members for provide home care to the patient.
- Teach relaxation techniques i.e like watching TV ,reading news paper,meditation.
- Teach the family members about support the patient psychologically and physically
- Teach them about sign and symptoms of disease and complications, if any occur then
immediately consult with physician.
Medication
- Teach the patient and family member about time and frequency of taking medication.
- teach the family members for skip of drug may induce serious complication.
- Teach about side effects of medication.
- advice to complete the course of medication.
Follow up-
- Instruct the patient to review for re-checkup as a prescribed.
- Advise that if any side effects occur then report to the physician.
- Advice for regular CBC , liver function test, vital signs monitoring and to early detection
of complication
CONCLUSION
If untreated chronic kidney disease can progress to kidney failure and early cardiovascular
disease. early detection of symptoms and prompt management is necessary to prevent the further
complication and prevent the patient from life threatening condition.
BIBLIOGRAPHY
Brunner & Suddharth’s. Textbook of Medical Surgical Nursing; 11th edi; New Delhi:
Reed elseiver .- (p) LTD PG-1311-1316
http://wedmed.com.livert -disease
Lewis textbook of medical surgical nursing ;ninth edition ;New delhi; Elsevier p- 1206-
1209
