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57yo Male with Cirrhosis of Liver & Pancreatitis - Coggle Diagram
57yo Male with Cirrhosis of Liver & Pancreatitis
Nutrition
constipated unless consistently taking lactulose
reports nausea and vomiting
reports recent decrease in appetite
reports weight loss of 20lbs over past 6months
pancreatitis is exacerbated by food
client states "I haven't eaten in three days because of the pain"
poor skin turgor
nails are dry and brittle - indicative of vitamin deficiency
broken arm last year - current diet may be insufficient in calcium and vitamin d
Medication
client has difficulty in obtaining his medications
NKA
4mg Morphine Sulfate Q2hrs PRN for pain control
Psychosocial
lives with recently divorced sister and her four children
uses alcohol and tobacco
client states he has dealt with his health problems at home by "having a drink and a smoke"
smokes 1pk/day with no plans of cessation
client states he has lost friends because of his alcohol consumption
client states he feels depressed and hopeless
Risk for Electrolyte Imbalance
client is taking two diuretics: spironolactone 100mg daily & furosemide 40mg daily
Lactulose 30mL daily 3x/day
preexitisng diagnosis of pancreatitis
client states "I haven't eaten in three days because of the pain"
Pain Management
pain is described as "aching"
pain is constant over the past three weeks
pain intensity is rated as a 7 on a 0-10 scale
pain is aggravated by food and alcohol
pain is located in stomach usually, but occasionally radiates around to client's back
4mg Morphine Sulfate Q2hrs PRN for pain control
Impaired Skin Integrity
client scores 16 on the Braden scale placing him at a high risk for impaired skin integrity
client's diet has been very poor over the past three days
client appears jaundiced with dry skin
spider nevi on chest
broken blood vessels on cheeks and nose
poor skin turgor
2x4cm reddened area on client's sacrum