What is the most likely reason for the patient's mild jaundice as observed in the initial assessment findings?

C) Mild hyperbilirubinemia due to liver dysfunction

A) Increased breakdown of red blood cells

B) Obstruction of the bile duct

C) Mild hyperbilirubinemia due to liver dysfunction

D) Excessive dietary intake of vitamin A

A patient with early-stage cirrhosis presents with mild jaundice and slightly elevated liver enzymes. Which of the following nursing interventions is most appropriate to help manage this patient's condition?

C) Recommend a low-sodium diet to help prevent fluid retention

A) Encourage a diet high in protein to support liver function

B) Advise regular use of over-the-counter acetaminophen for pain management

C) Recommend a low-sodium diet to help prevent fluid retention

D) Suggest daily alcohol consumption in moderation to reduce stress on the liver

What is the primary purpose of initiating a low-dose diuretic for a patient with ascites in this scenario?

C) To decrease bilirubin levels

D) To enhance platelet production

What is the most appropriate nursing action to prevent falls in a patient experiencing occasional lightheadedness due to diuretic therapy?

A) Encourage the patient to rise slowly from a sitting or lying position

B) Advise the patient to stop taking the diuretic until symptoms resolve

C) Increase the patient's fluid intake to at least 3 liters per day

D) Administer an additional dose of diuretic when lightheadedness occurs

A patient on a low-dose diuretic reports feeling lightheaded when standing up from a sitting position. What is the most appropriate nursing intervention to address this symptom?

B) Encourage the patient to drink more fluids and rise slowly from sitting or lying positions.

A) Advise the patient to increase their salt intake.

B) Encourage the patient to drink more fluids and rise slowly from sitting or lying positions.

C) Instruct the patient to decrease physical activity to prevent lightheadedness.

D) Suggest the patient take the diuretic at night to avoid symptoms during the day.

A patient with ascites is experiencing orthostatic hypotension due to diuretic therapy. Which nursing intervention is most appropriate to address this symptom?

C) Instruct the patient to change positions slowly to prevent dizziness

A) Encourage the patient to increase fluid intake as tolerated

B) Advise the patient to sit or lie down immediately after standing

C) Instruct the patient to change positions slowly to prevent dizziness

D) Recommend the patient take an additional dose of diuretic to manage ascites

What is the primary reason for reducing the diuretic dosage in this patient?

B) To manage orthostatic hypotension

cirrhosis - Nursing Case Study

Pathophysiology

• Primary mechanism: Chronic liver injury leads to repeated inflammation and repair, causing excess fibrous tissue (scarring) to replace healthy liver cells. This scarring disrupts normal liver function and architecture, impairing blood flow.

• Secondary mechanism: Scar tissue formation activates hepatic stellate cells, promoting further fibrosis. This results in increased resistance to blood flow through the liver, contributing to portal hypertension (high blood pressure in the portal vein).

• Key complication: Portal hypertension can cause complications such as varices (enlarged veins) that may bleed, ascites (fluid buildup in the abdomen), and impaired liver function, leading to symptoms like jaundice and confusion.

Patient Profile

Demographics:

45-year-old male, accountant

History:

• Key past medical history: Diagnosed with non-alcoholic fatty liver disease (NAFLD) 5 years ago

• Current medications: Ursodeoxycholic acid, Vitamin E

• Allergies: None

Current Presentation:

• Chief complaint: Mild fatigue

• Key symptoms: Occasional abdominal discomfort, slight jaundice

• Vital signs: Blood Pressure 120/80 mmHg, Heart Rate 78 bpm, Respiratory Rate 16 breaths/min, Temperature 98.6°F, Oxygen Saturation 98% on room air

Section 1

Initial Assessment Findings:

Upon initial assessment, the nurse notes that the patient presents with mild jaundice, evident by the slight yellowing of the sclera. The patient's abdomen is soft but slightly distended, with mild tenderness noted upon palpation. There is no evidence of ascites at this stage, and the patient's weight remains stable. The patient reports occasional episodes of mild pruritus, which he attributes to the jaundice. No spider angiomas or palmar erythema are observed during the skin examination, suggesting that the liver dysfunction is still at an early stage.

Laboratory results reveal mildly elevated liver enzymes, with ALT at 68 U/L and AST at 72 U/L, both slightly above the normal range. The patient's bilirubin level is 1.8 mg/dL, indicating mild hyperbilirubinemia, consistent with the observed jaundice. The albumin level is within normal limits at 4.2 g/dL, suggesting that the liver’s protein synthesis function is largely preserved. The platelet count is slightly decreased at 140,000/µL, potentially indicating early signs of portal hypertension, although no significant clinical symptoms of this are present. The INR is stable at 1.1, reflecting adequate coagulation status at this point.

These findings suggest that the patient's cirrhosis is in its early stages, primarily characterized by mild hyperbilirubinemia and slight portal hypertension without significant complications. The patient is advised to maintain regular follow-ups for monitoring liver function and potential progression of cirrhosis. The nurse emphasizes the importance of adhering to prescribed medications and lifestyle modifications, including a balanced diet low in sodium and regular physical activity, to support liver health and potentially slow disease progression. The next steps in care will focus on ongoing monitoring and prevention of more severe complications, such as variceal bleeding or significant ascites.

Section 2

Two months after the initial assessment, the patient returns for a follow-up appointment. During this visit, the nurse notes a slight increase in the severity of jaundice, with more pronounced yellowing of the sclera and skin. The patient reports increased episodes of pruritus, now affecting his sleep quality, prompting the need for further evaluation and management. Upon physical examination, the nurse observes that the patient's abdomen remains soft but is more distended than before, with mild discomfort reported upon deeper palpation. The presence of a slight fluid wave suggests early development of ascites, although still minimal.

Updated laboratory results show a gradual increase in liver enzymes, with ALT now at 78 U/L and AST at 82 U/L, indicating a mild progression of liver inflammation. The total bilirubin has risen to 2.3 mg/dL, correlating with the worsening jaundice. The platelet count has decreased further to 120,000/µL, suggesting increasing portal hypertension. Despite these changes, the INR remains stable at 1.2, indicating continued adequate coagulation status, and the albumin level is still within normal limits at 4.0 g/dL. These lab results highlight the importance of ongoing monitoring and adjustments to the patient's care plan.

In response to these findings, the healthcare team decides to adjust the patient's management plan. The nurse reinforces the importance of dietary modifications, emphasizing a low-sodium diet to help manage the budding ascites. The patient is educated on the use of antihistamines to manage pruritus and improve sleep. Additionally, the nurse schedules more frequent follow-up visits and lab tests to closely monitor liver function and detect any further progression of cirrhosis early. The patient is encouraged to continue abstaining from alcohol and to engage in moderate physical activity to support liver health. These interventions aim to prevent further complications and maintain the patient's quality of life as the disease progresses.

Section 3

Three weeks after the management adjustments, the patient returns for another follow-up appointment. During this visit, the nurse notes a slight improvement in the patient's pruritus, with the patient reporting that the antihistamines have helped reduce itching and improve sleep quality. However, the jaundice remains prominent, with continued yellowing of the sclera and skin. The patient's abdomen appears slightly more distended, and the patient reports feeling fuller sooner during meals, suggesting mild worsening of ascites.

Vital signs are stable, with blood pressure at 118/76 mmHg, heart rate at 78 beats per minute, respiratory rate at 16 breaths per minute, and an oxygen saturation of 98% on room air. Updated laboratory results reveal that the liver enzymes have remained relatively stable, with ALT at 80 U/L and AST at 85 U/L. The total bilirubin has increased slightly to 2.5 mg/dL, reflecting ongoing liver dysfunction. The platelet count has decreased further to 110,000/µL, indicating persistent portal hypertension, while the INR stays stable at 1.2 and albumin remains at 3.9 g/dL.

In light of these findings, the healthcare team decides to initiate a low-dose diuretic to help manage the ascites and prevent further fluid accumulation. The nurse provides education on the importance of adhering to the prescribed medication regimen, monitoring for side effects, and maintaining a low-sodium diet. The patient is also encouraged to keep a daily weight log to track fluid retention. Follow-up appointments and lab tests are scheduled more frequently to closely monitor the patient's response to the new intervention and ensure early detection of any further progression or complications. This approach aims to stabilize the patient's condition and maintain quality of life as the disease progresses.

Section 4

Two weeks after the introduction of a low-dose diuretic, the patient returns for another follow-up visit. During the initial assessment, the nurse notes that the patient's abdominal distension has slightly decreased, indicating that the diuretic is helping to manage the ascites. The patient reports feeling more comfortable and notices less early satiety during meals, suggesting an improvement in appetite. However, the patient mentions experiencing occasional lightheadedness, particularly when getting up from a sitting or lying position, which could be an early sign of diuretic-related dehydration or electrolyte imbalance.

Vital signs show a blood pressure of 110/70 mmHg, a slight decrease from previous readings, with a heart rate of 82 beats per minute, respiratory rate of 16 breaths per minute, and oxygen saturation of 97% on room air. These stable vital signs, despite the decrease in blood pressure, suggest the need for close monitoring but are not immediately alarming. The nurse checks the patient’s electrolyte levels, revealing a sodium level of 135 mEq/L and a potassium level of 3.5 mEq/L, both within the normal range but on the lower end, reinforcing the importance of monitoring for potential diuretic side effects.

Based on these findings, the healthcare team decides to maintain the current diuretic dosage but emphasizes the importance of monitoring orthostatic vital signs and reinforcing the need for adequate fluid intake. The nurse educates the patient on recognizing signs of dehydration, such as increased thirst, dry mouth, and dizziness, and advises on the importance of rising slowly from sitting or lying positions to prevent falls. The healthcare team schedules a follow-up appointment and lab tests in one week to ensure the patient's safety and to continue assessing the effectiveness of the intervention. This proactive monitoring and education aim to maintain the patient's stability and prevent further complications.

Section 5

A week later, the patient returns for their follow-up appointment. During the initial assessment, the nurse observes that the patient's abdominal distension has further decreased, suggesting continued effectiveness of the diuretic therapy in managing the ascites. The patient reports an improvement in overall energy levels and appetite, indicating a positive response to the current treatment plan. However, the patient also mentions experiencing more frequent episodes of lightheadedness when changing positions, a symptom that has become more pronounced since the last visit.

The nurse conducts orthostatic vital sign measurements to further investigate the patient's symptoms. The results show a blood pressure of 108/68 mmHg while lying down and 96/60 mmHg upon standing, with an associated increase in heart rate from 80 to 94 beats per minute. These findings confirm the presence of orthostatic hypotension, likely related to the diuretic use. The nurse also reviews the patient's latest lab results, which reveal a sodium level of 134 mEq/L and a potassium level of 3.4 mEq/L, both slightly lower than the previous week, indicating a trend that requires close monitoring.

In response to these findings, the healthcare team decides to adjust the patient's care plan. They recommend reducing the diuretic dosage to alleviate the symptoms of orthostatic hypotension while maintaining the positive effects on ascites. The nurse reinforces education on maintaining adequate hydration, recognizing signs of dehydration, and implementing slow position changes. Additionally, the team schedules more frequent follow-up visits and lab tests to closely monitor the patient's electrolyte levels and blood pressure response. This careful adjustment ensures the continued safety and stability of the patient as they manage their cirrhosis with minimal complications.