Mr. Smith has cirrhosis. Briefly discuss the pathophysiology of this disease.   Explain how hepatic encephalopathy is related to cirrhosis.   Upon initial assessment, the nurse did not note any asterixis. What is asterixis and how would one assess for it?

Case Study Practice

Case Introduction:

Mr. Smith is a 55 year-old African-American male with a history of cirrhosis.  He lives with his wife and teenage sons, ages 19 and 16.  His wife brought him to the emergency department because she noticed that Mr. Smith showed increased confusion and was having difficulty walking. His wife states, “He is probably acting a little funny because he is sleep deprived.  He hasn’t slept very much in the past few days.” His wife reports that he has a history of alcoholism and drank one quart of hard liquor each day for three years prior to his diagnosis of cirrhosis (diagnosed 2 years ago). He is currently unemployed and has been on disability for four years.

Relevant medical history:

Past medical history:  Cirrhosis secondary to alcoholic hepatitis, Hypertension, Esophageal Varices

Coexisting Condition:  Ascites

Pharmacologic: Lactulose; Neomycin sulfate; Inderal

Assessment:

Mr. Smith’s vital signs are as follows: BP - 136/68, pulse 88, and respiration rate 18.  His oxygen saturation is 98% on room air, and he is afebrile. Mr. Smith is awake, alert and orientated to person only.  His speech is slow and he appears lethargic.  The nurse notices a foul odor to his breath.  Upon physical examination Mr. Smith has a distended abdomen, but no apparent asterixis. He has 1+ pitting edema in his lower extremities. Lung sounds are diminished in the bases bilaterally; S1 & S2 heard (normal).

The physician requests an abdominal ultrasound, which reveals fatty infiltrates of the liver, an enlarged spleen, a polyp in his gallbladder, and a moderate amount of ascites. 

Laboratory results:

White blood cell count of 4.8 cells/mm³

RBC 2.94 million/mm³

Hgb 9.8 g/dl, Hct 28.2%

Sodium 145mEq/L, potassium 3.1 mEq/L, chloride 112 mEq/L, carbon dioxide 25mEq/L

Serum blood glucose is 112 mg/dL

BUN is 42 mg/dL, creatinine is 1.8 mg/dL.

Total protein 4.7 g/dL, albumin 2.8 g/dL, total bilirubin 1.8 mg/dL

AST 17u/L, ALT 20u/L

Prothrombin time - 13.1 seconds

Ammonia level is 124 umol/L

Urinalysis results are within normal limits

Admitting Physician Orders: 

Intravenous fluids of D5 ½ NS are started at 100 ml/hr

Mediations prescribed include Lactulose, Neomycin sulfate, Spironolactone

Daily weights, strict intake and output documentation, monitoring for stools for occult blood, Neurological assessment every four hours

Low protein, low sodium diet

Case Study Questions:

1. Mr. Smith has cirrhosis. Briefly discuss the pathophysiology of this disease.

1. Explain how hepatic encephalopathy is related to cirrhosis.

1. Upon initial assessment, the nurse did not note any asterixis. What is asterixis and how would one assess for it?

1. Identify the clinical manifestations of hepatic encephalopathy that are consistent with Mr. Smith’s presentation.

1. Identify which of Mr. Smith’s laboratory results are abnormal and provide a rationale for why each is outside the normal range.

1. Define ascites. Explain what causes ascites and how the nurse will assess for this condition.

1. Mr. Smith has been prescribed 30 mL of lactulose every 6 hours and neomycin sulfate 500 mg four times a day, and Spironolactone 40mg PO BID. Explain why each of these medications have been prescribed for the client. What assessments prior to administration of these medications, and post administration are needed?

1. Provide an explanation for the low protein, low sodium diet the physician prescribed for Mr. Smith.

1. Create a sample menu/meal for Mr. Smith based on his prescribed diet. What foods should be avoided?

1. Additional diagnostic testing reveals that Mr. Smith has esophageal varices, which the physician wants to treat this complication with endoscopic variceal ligation (EVL). Discuss what esophageal varices are and the EVL procedure used to treat them.

1. Identify two priority nursing diagnoses for Mr. Smith. Make sure you include all components of the diagnoses (include r/t and aeb information). Include two nursing interventions for each diagnosis.