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Mr. Scottaline (was diagnosed prior to admission (Depression Mood…

- - - - Health Assessment (admission)
        Vital signs:
        B/P 132/82 (hypertension); P 88; RR 24 (tachypnea); O2 sat 90% on RA (hypoxia); T 37 C/98.6 F;
        W 106kg/235lbs; BMI 26.7 (overweight);.
        Physical Assessment:
        Neuro: Alert, oriented to person, place, year and month but not today; neuro exam without motor or sensory deficits, c/o on lethargic.
        Respiratory: unremarkable.
        CV: 3+ edema to mid-calf/pedal pulses barely palpable bilaterally; weight gain more than 5kg this month
        GI:Abdomen distended with fluid noted, mild tenderness to palpation; c/o on the loss of appetite in the last one week, nausea and vomiting, the spleen is enlarged
        ; MSK: mobilizes slowly and unsteady
        Integum: spider telangiectasia on the face and upper chest, palms are reddened;
        EENT: Sclera is icteric
        
        led to
        
        Paracentesis - 5L of fluid removed; received three vials of IV albumin 25%; referred to an oncologist and gastroenterologist.
        
        followed by
        
        Assessment (day 2)
        Vital signs: B/P 109/58 ( relative hypotension?); P 99 (tachycardia); R 20 (tachypnea); O2 sat 93% on RA; T 37.8 C/100 F;
        W 100 kg/220 lbs BMI 25.3 (overweight)
        
        followed by
        
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        led to
        
        Treatment Plan
        General: Symptomatic treatment; Parenthesis to alleviate ascites
        Diet: Restricted sodium consumption; Restricted fluid intake; No alcohol intake; High-calorie, high-fiber diet; Multiple small meals
        Activity : Frequent rest periods
        Medications: Chemotherapeutic drugs; Analgesics; Diuretics
        Procedures: Radiation therapy ; Cryotherapy
        Surgery: Embolization ; Resection ; Liver transplantation; CyberKnife stereotactic radiosurgery; Ablative therapies
- - - - possibly related
    - - may contributed to
- - - - Assessment: Observe for changes in behavior and mentation: lethargy, confusion, drowsiness, slowing or slurring of speech, and irritability.
        
        leads to
        
        Nursing Dx 4. Disturbed thought processes and potential for mental deterioration related to abnormal liver function and increased serum ammonia level
        
        leads to
        
        Outcomes:
        Adheres to protein restriction.
        Demonstrates an interest in events and activities in environment.
        Demonstrates the normal attention span.
        Follows and participates in conversation appropriately.
        Is oriented to person, place, and time.
        Remains in bed when indicated.
        Reports no urinary or fecal incontinence.
        Experiences no seizures.
        No neurological or respiratory depression.
        Develops no cognitive impairments, but if they develop, they are quickly identified and treated, enhancing the potential of recovery.
        The patient describes adequate feelings of coping and lowered anxiety, demonstrate the ability to listen and to make decisions as able.
        
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    - - Assessment:
        Assess the degree of discomfort related to pruritus and edema.
        Assess and record the degree of jaundice and extent of edema.
        
        leads to
        
        Nursing Dx 3 Impaired skin integrity related to pruritus from jaundice and edema
        
        leads to
        
        Outcomes:
        Exhibits intact skin without redness, excoriation, or breakdown.
        Reports relief from pruritus.
        Exhibits no skin excoriation from scratching.
        Uses nondrying soaps and lotions. States rationale for use of nondrying soaps and lotions.
        Exhibits reduced edema of dependent parts of the body.
        Exhibits no areas of skin breakdown.
        Exhibits decreased edema; normal skin turgor
        
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    - - Assessment:
        Assess respiratory status, respiratory rate, presence of dyspnea. Auscultate lungs, noting diminished breath sounds and adventitious sounds.
        Assess degree of peripheral edema. Measure abdominal girth.
        Monitor intake and output.
        Monitor BP. Note JVD and abdominal vein distension.
        Monitor serum albumin and electrolytes
        
        leads to
        
        NDx 2. Excess Fluid Volume, Extra vascular related to hypo-albuminemia, increased portal venous pressure as evidenced by increased abdominal girth, weight gain, peripheral edema
        
        leads to
        
        Outcomes:
        Experiences a decrease in ascites formation and accumulation evidenced by decrease abdominal girth and weight while remaining hydrated
        Consumes diet low in sodium and within prescribed ﬂfluid restriction.
        Takes diuretics, potassium, and protein supplements as indicated without experiencing side effects.
        Exhibits increased urine output.
        
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    - - Assessment: Assess level of activity tolerance and degree of fatigue, lethargy, and malaise when performing routine activities of daily living.
        
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        Nursing Dx 5 Activity intolerance related to fatigue, lethargy, and malaise
        
        leads to
        
        Outcomes:
        Exhibits increased interest in activities and events.
        Participates in activities and gradually increases exercise within physical limits.
        Reports increased strength and wellbeing.
        Reports of the absence of abdominal pain and discomfort.
        Plans activities to allow ample periods of rest.
        Takes vitamins as prescribed
        
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    - - Assessment:
        Assess dietary intake and nutritional status through diet history and diary, daily weight measurements, and laboratory data.
        Determine interest in eating, the ability to chew, swallow, and taste. Discuss eating habits, including food preferences, intolerances, or aversions; assess the availability and use of support systems; determine dietary intake and perform calorie count.
        Assess weigh and laboratory test (electrolytes, glucose, albumin and ammonia level, coagulation profile)
        
        leads to
        
        NDx 1: Imbalanced Nutrition: Less than Body Requirements related to l to anorexia, nausea, or malabsorption as evidenced by fatigue, generalized weakness, imbalances in nutritional studies
        
        leads to
        
        Outcomes: Before discharge, the patient will report increased appetite, take medications for gastrointestinal disorders as prescribed as well as he will to be able to identiﬁe rationale for smaller, frequent meals, achieve adequate nutritional intake evidenced by consumption recommended number of calories, laboratory data showed results within the normal range, to state the rationale for dietary modiﬁcations and demonstrate a selection of foods or meals that will maintain a stable weight without ﬂuid retention
        
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- - - - changes in appetite, sleep disturbances, restlessness or lethargy, and decreased concentration
        
        managed by
        
        Treatment:
        Paroxetine 40 mg PO daily
        SSRI, antidepressant(Depression)
        Trazodone 50 mg PO daily at bedtime
        antidepressant (Depression, Insomnia )
  - - - Complications::
        inability to metabolize bilirubin and resultant jaundice;
        difficulty producing serum proteins, including albumin and certain clotting factors;
        hyperdynamic circulation and decreased vasomotor tone;
        pulmonary changes and sometimes cyanosis;
        changes in nitrogen metabolism;
        difficulty metabolizing some hormones;
        
        resulting in
        
        Ascites
        Muscle wasting
        Coagulopathy
        Portal hypertension
        Bleeding esophageal varices
        Hepatic encephalopathy
        Hepatorenal syndrome
        Spontaneous bacterial peritonitis
        Hepatopulmonary syndrome
        Hepatocellular carcinoma
        Hepatic failure
        Death
        
        managed by
        
        Treatment : Paracentesis and Albumin transfusion
        Spironolactone 100 mg PO daily - for ascites or edema
        Furosemide 40 mg PO every morning - for ascites or edema
        Loratadine 10 mg PO daily - for pruritus
        Folic Acid 0.2 mg PO daily - to enhance the metabolism of formic acid
        Thiamine 5 mg PO daily - to increase the formation of glycine
        Multivitamins 1 Tab PO daily - in malabsorption syndromes, dietary deficiencies
        Gabapentin 100 mg PO three times a day - for pruritus
        Lactulose 30 mL PO three times a day - encephalitis
      - Hepatocellular Carcinoma (HCC)
        
        managed by