cirrhosis - Nursing Case Study

Pathophysiology

• Primary mechanism: Chronic liver injury, often from alcohol or hepatitis, leads to repeated inflammation. Over time, this causes liver cells to die and be replaced by scar tissue, or fibrosis, which disrupts normal liver function.

• Secondary mechanism: Fibrosis results in the formation of nodules that block blood flow through the liver, leading to increased pressure in the portal vein (portal hypertension). This affects blood supply and further impairs liver function.

• Key complication: Portal hypertension can cause fluid buildup in the abdomen (ascites) and increased risk of bleeding from dilated veins (varices), posing significant health risks.

Patient Profile

Demographics:

45-year-old male, office worker

History:

• Key past medical history: Hepatitis B infection diagnosed 10 years ago

• Current medications: Tenofovir 300 mg once daily

• Allergies: No known drug allergies

Current Presentation:

• Chief complaint: Routine check-up, no specific complaints

• Key symptoms: Occasional fatigue, mild abdominal discomfort

• Vital signs: Blood pressure 120/80 mmHg, heart rate 72 bpm, respiratory rate 16 breaths/min, temperature 98.6°F, BMI 24.5

Section 1

Initial Assessment Findings:

During the routine check-up, the nurse conducts a thorough assessment of the patient. The patient appears well-nourished and in no acute distress. On inspection, there is no jaundice present. The abdominal examination reveals a mildly distended abdomen with slight tenderness in the right upper quadrant, although there is no shifting dullness or fluid wave to suggest significant ascites at this stage. The liver edge is palpable, firm, and slightly enlarged upon palpation, consistent with early-stage cirrhosis. The rest of the physical examination, including cardiovascular and respiratory assessments, is unremarkable.

The nurse also reviews recent laboratory results, which show mildly elevated liver enzymes, including ALT and AST, indicative of ongoing liver inflammation. The patient's albumin and bilirubin levels remain within normal limits, suggesting preserved liver function. Platelet count is slightly decreased at 140,000/mm³, which could be an early indication of portal hypertension. The patient denies any history of gastrointestinal bleeding or signs of varices, such as hematemesis or melena.

Given these findings, the nurse plans to educate the patient on lifestyle modifications to slow disease progression, such as maintaining a healthy diet and avoiding alcohol. The nurse also discusses the importance of regular follow-up appointments and monitoring for potential complications. The healthcare team considers additional diagnostic imaging, like an abdominal ultrasound, to further assess liver structure and blood flow, laying the groundwork for ongoing management of the patient's condition.

Section 2

New Diagnostic Results:

Following the initial assessment, the healthcare team proceeds with the recommended abdominal ultrasound to gain further insight into the patient's liver condition. The ultrasound results reveal a slightly nodular liver surface, characteristic of early cirrhosis, with no significant ascites or splenomegaly detected. Doppler studies included in the ultrasound show normal hepatic blood flow, suggesting that portal hypertension is not yet a significant concern. These findings reinforce the early-stage diagnosis and provide reassurance that there are no acute complications at this time.

In addition to the ultrasound, the team orders a FibroScan, a non-invasive test that measures liver stiffness to assess the extent of fibrosis. The results indicate a mild increase in liver stiffness, affirming the presence of early fibrosis but without extensive scarring. These diagnostic findings are consistent with the patient’s stable condition and support the plan to manage the disease with lifestyle modifications and regular monitoring.

Based on these results, the nurse revisits the education plan with the patient, emphasizing the importance of a balanced diet rich in fruits, vegetables, and lean proteins, and strictly avoiding alcohol to prevent further liver damage. The patient is also encouraged to engage in regular physical activity, which can help maintain overall health and potentially improve liver function. The nurse schedules a follow-up appointment in three months to reassess the patient's condition, review any new symptoms, and update the care plan as necessary.

Section 3

Three months later, the patient returns for their follow-up appointment. During the initial assessment, the nurse notes that the patient appears well-nourished and reports adhering to the recommended dietary and lifestyle changes. The patient mentions feeling more energetic and has been able to incorporate walking into their daily routine, which they enjoy. Vital signs are stable: blood pressure is 120/80 mmHg, heart rate is 72 beats per minute, respiratory rate is 16 breaths per minute, and the patient is afebrile. The nurse conducts a physical examination, noting no signs of jaundice or edema, and the abdomen remains soft with no tenderness or distention.

Laboratory tests are ordered to monitor liver function and assess for any progression of the disease. The results show liver enzymes slightly elevated but stable: ALT is 55 U/L and AST is 60 U/L, both slightly above the normal range but consistent with previous results. Albumin levels are normal at 4.0 g/dL, indicating good nutritional status and liver function, while bilirubin remains within normal limits at 0.8 mg/dL. The patient's INR is 1.1, suggesting adequate liver protein synthesis and coagulation function.

Based on these findings, the healthcare team is encouraged by the patient's progress and the stability of their condition. The nurse reinforces the importance of ongoing lifestyle modifications and regular monitoring to prevent disease progression. The patient expresses understanding and is motivated to continue their current regimen. The nurse schedules the next follow-up in six months, emphasizing the need to return sooner if any new symptoms or concerns arise. This proactive approach aims to maintain the patient's stable status and address any issues early should they develop.

Section 4

Three months after the last follow-up, the patient returns for their scheduled appointment. During the initial assessment, the nurse observes that the patient continues to appear well-nourished and reports feeling even more energetic, attributing this to maintaining a balanced diet and regular exercise. The patient proudly shares that they have been participating in a local walking group, which has helped them remain motivated and socially engaged. Vital signs during this visit remain stable: blood pressure is 118/78 mmHg, heart rate is 70 beats per minute, respiratory rate is 18 breaths per minute, and the patient is afebrile. The physical examination reveals no signs of jaundice, edema, or ascites, and the abdomen is still soft with no tenderness or distention.

New laboratory tests are ordered to evaluate the patient's liver function and overall health. The results show that liver enzymes have slightly decreased, with ALT at 52 U/L and AST at 58 U/L, indicating a positive trend. Albumin levels remain within normal limits at 4.1 g/dL, reinforcing the patient's good nutritional status and stable liver function. Bilirubin levels are unchanged at 0.7 mg/dL, and the patient's INR is consistent at 1.1, confirming ongoing adequate liver synthesis and coagulation function. These diagnostic results suggest that the patient's adherence to lifestyle modifications continues to be effective in managing their condition and preventing progression.

The healthcare team is pleased with the patient's progress and stability, highlighting the importance of continued adherence to their current regimen. The nurse discusses the ongoing need for regular monitoring and encourages the patient to remain vigilant for any changes in symptoms. The patient expresses confidence and commitment to maintaining their health, understanding the significance of early intervention should new symptoms arise. The next follow-up is scheduled for another six months, with the option to return sooner if needed. This careful monitoring aims to ensure the patient's condition remains stable and any potential complications are addressed promptly.

Section 5

One month after the latest follow-up, the patient contacts the clinic with concerns about new symptoms. During a phone call with the nurse, the patient reports experiencing mild fatigue and intermittent abdominal discomfort, which are new since the last visit. The nurse advises the patient to come in for an evaluation to ensure these symptoms are not indicative of a change in their condition. Upon arrival, the patient still appears well-nourished, but the nurse notes a slight increase in heart rate at 78 beats per minute and a mildly elevated blood pressure of 130/82 mmHg. The patient's respiratory rate is steady at 18 breaths per minute, and their temperature remains normal.

The physical examination reveals a soft abdomen with very mild tenderness in the right upper quadrant but no significant distention or rebound tenderness. There is no jaundice or edema present. Given these findings, the healthcare team decides to perform additional laboratory tests to further investigate the cause of the patient's symptoms. The lab results show a slight increase in liver enzymes, with ALT now at 58 U/L and AST at 65 U/L, suggesting a minor elevation compared to the previous values. Albumin remains stable at 4.0 g/dL, and bilirubin is slightly elevated at 0.9 mg/dL. The INR remains at 1.1, indicating continued adequate liver function regarding coagulation.

These changes prompt the healthcare team to reinforce the importance of the patient's lifestyle modifications, suggesting a possible need for dietary adjustments to address the abdominal discomfort. The nurse emphasizes the significance of staying hydrated, maintaining a low-sodium diet, and monitoring any new symptoms. The patient is reassured that these changes may be transient and manageable with minor adjustments to their regimen. A follow-up appointment is scheduled for two months to ensure these symptoms resolve and to monitor any further developments, encouraging proactive communication with the clinic should symptoms persist or worsen.