CIRRHOSIS CASE STUDY 2Cirrhosis
John Richards, 45 years old
Primary Concept
Nutrition
Interrelated Concepts (In order of emphasis)
1. Fluid and
... [Show More] Electrolyte Balance
CIRRHOSIS CASE STUDY 32. Perfusion
3. Cognition
4. Clinical Judgment
FUNDAMENTAL Reasoning Case Study: STUDENT
Cirrhosis
History of Present Problem:
John Richards is a 45-year-old male who presents to the emergency department (ED) with abdominal pain and
worsening nausea and vomiting the past three days that have not resolved. He is feeling more fatigued and has
had a poor appetite the past month. He denies any ETOH (alcohol) intake the past week, but admits to episodic
binge drinking on most weekends. John weighs 150 pounds (68.2 kg) and is 6'0" (BMI 17.6). You are the nurse
responsible for his care.
Personal/Social History:
John is single, has never married, and lives alone in his own apartment. He has struggled with heroin use/abuse
in the past, but has not used in the past two years. John is currently unemployed and has no health insurance. He
was diagnosed with hepatitis C ten years ago but has had minimal follow-up medical care since.
What data from the histories is RELEVANT and has clinical significance to the nurse?
RELEVANT Data from Present
Problem:
Clinical Significance:
Fatigue
Lack of appetite
Hepatitis C
He has not been complying with
This warning and signs and symptoms indicate the presence of
complications with the patient’s G.I system (Przybyłkowski et al.,
2014).
These vital signs also direct the nurse on which tests to carry out on
CIRRHOSIS CASE STUDY 4prescriptions
Malnourishment
Nausea and vomiting
the patient.
RELEVANT Data from Social History: Clinical Significance:
He is living alone
History of heroin use
He is unemployed and has no health
insurance
This history provides the baseline of the present habits of the
patient
From this history, the nurse can identify priority and treatment
Mismanaging hepatitis and continued loss of alcohol causes further
complications like liver damage(Przybyłkowski et al., 2014).
Developing Nurse Thinking by Identifying Significance of Clinical Data
Current VS: P-Q-R-S-T Pain Assessment (5th VS):
T: 100.5 F/38.1 C (oral) Provoking/Palliativ
e:
Nothing/nothing
P: 110 (regular) Quality: Ache
R: 20 Region/Radiation: RUQ/epigastrickeith RN cirrhosis
CIRRHOSIS CASE STUDY 5BP: 128/88 Severity: 6/10
O2 sat: 95% RA Timing: Continuous
Orthostatic BP’s:
Position: HR: BP:
Lying 110 128/88
Standing 132 124/80
What VS data is RELEVANT and must be recognized as clinically significant by the nurse?
RELEVANT VS Data: Rationale:
Temperature : 100.5 (oral)
Pulse rate : 110 (regular)
RUQ pain
Orthostatic changes
The rising pulse rate and temperatures indicate the presence of infection and
pain
Current Assessment:
GENERAL
APPEARANCE:
Appears uncomfortable, body tense, occasional facial grimacing
RESP: Breath sounds clear with equal aeration bilaterally, nonlabored respiratory effort
CARDIAC: Pink, warm [Show Less]