Presentedto the STI College Global City

College of Nursing

In Partial Fulfillment of the requirement in the

Subject Head Nursing Practice

Bachelor of Science in Nursing

Case Presentation

Liver Abscess

Gamotin, Trixie Anne G.

Poblete, Justine L.

Roldan, Lynette

_______________________________

Level IV BSN Students Group 5

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TABLE OF CONTENTS

i. Title Page ……………………………………………………………………………………………………… 1

ii. Table of Contents …………………………………………………………………………………………. 2

iii. Acknowledgements ………………………………………………………………………………………. 3

iv. Introduction ………………………………………………………………………………………………….. 5

v. Objectives ……………………………………………………………………………………………………... 7

vi. Biographic Data …………………………………………………………………………………………….. 8

vii. Nursing History ……………………………………………………………………………………………… 9

viii. Gordon’s Pattern of Healthcare …………………………………………………………………….. 11

ix. Physical Assessment ……………………………………………………………………………………… 16

x. Laboratory Studies/Diagnostic Studies ………………………………………………………….. 18

xi. Medications ………………………………………………………………………………………………….. 23

xii. Anatomy and Physiology ………………………………………………………………………………. 34

xiii. Pathophysiology …………………………………………………………………………………………… 36

xiv. Nursing Care Plan

a) Actual ………………………………………………………………………………………………. 38

b) Risk …………………………………………………………………………………………………. 41

c) Wellness …………………………………………………………………………………………. 43

xv. Evaluation of Case Presentation ………………………………………………………………….. 44

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ACKNOWLEDGEMENTS

The success of this case presentation has been made possible by the invaluable help of the

following:

Our almighty God for His divine guidance and the knowledge He bestowed upon us.

STI College Global City - College of Nursing, for giving the students the opportunity to

experience this related learning. Through this study we gained numerous knowledge, experience and

insights.

Tondo Medical Center Hospital &it’s Staff, for allowing us to interview, render care to our client

and giving us access to study & review client’s chart.

The patient, for his invaluable help by providing the presentor’s all the essential data and

informations that they need for case presentation as well as the trust that the nursing students will

keep anonymity of his identity.

Dr. Miguel E. Mangada, Dean of STI College Global City of Nursing for the guidance, for

believing in our capabilities and for inspiring the group’s to be more productive student nurses and

citizen of the country.

Mr. Rudy Anthony Reyes and Mrs. Corazon Duran, the group’s clinical instructors for their

support and advices they have given them, for all the word of encouragement, and for sharing their

knowledge and most especially for believing in the strengths and capabilities of the entire class

Ms. Marison Magpantay, the group’s adviser for the support and contributions not merely with

the case study but also for sharing her knowledge.

The rest of the faculty, for giving their free assistance and sharing their knowledge as the group

this case presentation

To the presentor’s parents, for providing financial support for showing their unending love and

care to all the group’s endeavors is to each and every one member of the presenters,

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As we realized that as we took Nursing as our future profession we thank you for the

cooperation and understanding each has shown for the completion of this task.

And to those whom we haven’t mentioned, the humblest gratitude of the group are yours.

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INTRODUCTION

Liver abscess is a pus-filled cyst in the liver.The liver abscess has a thin capsular wall with a

necroticcentre composed of a thick fluid. Typically,abscess fluid is odourless, resembling ‘chocolate

syrup’ oranchovy paste’ in half, and bacteriologically sterile, althoughsecondary bacterial invasion may

occur.

The liver is an organ in the digestive system that assists the digestive process and carries out

many other essential functions. These functions include producing bile to help break down food into

energy; creating essential substances, such as hormones; cleaning toxins from the blood, including those

from medication, alcohol and drugs; and controlling fat storage and cholesterol production and release.

The condition can be caused by infections spread directly from nearby structures, such as the

bile-draining tubes, from the appendix or intestines, or carried in the bloodstream from more distant

parts of the body.It can also develop as a result of surgery or other trauma to the liver.

Liver abscess is usually treatable and often can be cured with a course of antibiotics or a

combination of antibiotics and a surgical procedure to drain the abscessdepending on the size, number,

and complexity of the abscess(es) such the following cases:

a) Abscess with intra-abdominal pathology requiring surgery

b) Ascitis

c) Multiple large abscesses

d) Abscess which cannot be drained percutaneously

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If Left untreated, however, a liver abscess can burst and spread the infection, leading to sepsis, a life-

threatening bacterial blood infection.

ETIOLOGY

The 3 major forms of liver abscess, classified by etiology, are as follows:

Pyogenic abscess, which is most often polymicrobial, accounts for 80% of hepatic abscess cases

in the United States.

o Maybe of biliary portal, arterial, or traumatic origin

o Ascending infection of the biliary tree secondary to obstruction is now the most

identifiable cause of PLA.

o Etiology of biliary obstruction geographical diffrence

Western countries this scenario is common in patients with malignant disease

(Tumors)

Asia, gall stone disease and hepatolithiasis are more common.

Amebic abscess due to Entamoebahistolytica accounts for 10% of cases.

o considered in endemic area (naturally present in the area)

o Usually single and mostly found in the rightlobe of the liver.

o Koch describe amoeba as the cause of liver abscess

Fungal abscess, most often due to Candida species, accounts for less than 10% of cases.

Liver abscess is usually treatable and often can be cured with a course of antibiotics or a

combination of antibiotics and a surgical procedure to drain the abscess depending on the size, number,

and complexity of the abscess.

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If Left untreated, however, a liver abscess can burst and spread the infection, leading to sepsis, a

life-threatening bacterial blood infection.

OBJECTIVES

General objective

This case presentation was designed to develop a holistic and patient centered nursing

care and responsibilities. This is to broaden the knowledge of the presenters as well as

the audience with regards to Liver Abscess; this is also designed to enhance skills and

attitudes in the application of nursing process and management of the disease.

Specific objectives

1. For the participants/critics, for us presenters & significant others to have a better

understanding on the disease process.

2. To have the pathophysiology and to trace the occurrence of Liver abscess.

3. To utilize properly the nursing process (assessment, diagnosis, planning, intervention,

evaluation) as the framework for the care of the patient.

4. To learn various medications, its condition, adverse effects & accompanying nursing

responsibilities.

5. To put into action what we have learned in the school (such as nursing process) and

apply our knowledge in providing quality and individualized nursing care.

6. To enhance group’s attitude, like discipline, cooperation, leadership abilities and

teamwork in making and presenting a case presentation.

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BIOGRAPHIC DATA

Name: Mr.JLT

Address: 19-F Aquino St. Nilungan, City of Malabon

Age: 50 years old

Sex: Male

Religious Affiliations: Roman Catholic

Occupation: Construction Worker (Contractual)

Marital Status: Married

Room & Bed number: Male Gastro, Medicine Ward

Admission: January 24, 2013/5:30PM

Chief Complaint: Severe Stomach ache and vomitting

Diagnosis: Liver Abscess

Attending Physician: Dr. N.P. M.D

Hospital: Tondo Medical Center

North Bay Boulevard, Balut, Tondo, Manila

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NURSING HISTORY

1. History of Present Illness: Prior to admission the patient experienced severe stomach ache at right

lower quadrant of the stomach accompanied with vomiting. Patient verbalized that the pain is cramp-

like; the duration of the pain comes strongly for a while and then lessens its intensity for a while and the

pain gets triggered and become worse after eating. Vomitus of the patient is clear and water like.

2. Family History of Illness

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GRANDFATHERHYPERTENSIONGRANDFATHERHYPERTENSION

GRANDMOTHERHEART ATTACK

GRANDFATHERUNKNOWN

GRANDFATHERUNKNOWN

GRANDMOTHERUNKNOWN

FATHERTUBERCULOSI

S

FATHERTUBERCULOSI

S

BROTHER53

HYPERTENSION

BROTHER53

HYPERTENSION

MR. JLT50

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MR. JLT50

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MOTHERHYPERTENSIO

N

MOTHERHYPERTENSIO

N

SISTER45

BREAST CA

SISTER45

BREAST CA

BROTHER42

VEHICULAR

ACCIDENT

BROTHER42

VEHICULAR

ACCIDENT

BROTHER39

HYPERTENSION

BROTHER39

HYPERTENSION

LEGEND

ALIVE

DECEASED

3. Childhood Illness:

The patient suffered from seasonal cough and colds as well as fever during younger years.

4. Hospitalization history:

Patient had past operation when he was 17 years old. He had cholecystectomy.

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GORDON’S PATTERN OF HEALTHCARE

Activities of Daily Livings

Before Hospitalization During Hospitalization Interpretation and Analysis

1. Health Perception – Health Management Pattern

“Bago ako maospital hindi ako ganun kaalaga sa sarili ko. Kapag nagkakasakit ako, yung mga lagnat at sipon o kya konting sakit ng tyan lang hindi ko na pinapansin. Hinahayaan ko nalang at pinapalipas hanggang sa mawala.”

“Ngayon na naospital na ako natuto nako ng leksyon, mabuti ng gamutin agad yung mga simpleng sakit kase kapag napabayaan lalong mahirap gamutin. Yung simpleng sakit kc kaunting pera lang ang mauubos at malaki ang posibilidad na gumaling, pag pinapatagal lalo lang nagiging magastos at mahirap.”

Hospitalization affects the health perception and management of the patient. The client became more conscious with his health and learned that even simple diseases can worsen and threaten his life. He became more conscious with regards to medical treatments that he needs.

2. Nutrition – Metabolic Pattern

“Malakas akong kumain pero hindi naman ako mahilig sa baboy, wala kasi kming pambili non. Madalas kong kainin ay isda, hindi rin ako masyadong mahilig sa gulay. Nakakadalawang kuha ako ng kanin kada kain ”

“Ngayong naospital ako, humina ako kumain kasi lage ako walang gana, di kasi ganun kasarap ang pagkain dito sa ospital at saka sumasakit ang tyan ko kapag napapadami ang kain ko. Halos dalawang subo pa lang wala na ako gana.

Nutrition metabolic pattern of the patient has been affected due to the different taste of food served to him on the hospital and at home. Too much eating also affects his condition so he is limiting his self with regards to foods he eat.

3. Elimination Pattern “Tuwing umaga sanay talaga ako na dumudumi,madalas pagkagising ko. Mga alas-singko ng umaga. Madalang akong umihi dahil hindi ako palainom ng tubig”

“Nahihirapan ako mapadumi dito sa ospital,naninibago siguro ako, pero palage padin naman ako umaga napapadumi hindi nga lang araw-araw. Hindi ko na matandaan kung kada ilang araw, kada ikalawang araw yata. Isang beses lang sa

Elimination pattern of the patient was affected; contributing factors includes the change in environment he is not used to defecate on other toilets and the decrease food intake of the patient.

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isang araw ako napapadumi. Yung pag ihi ko naman maya’t maya kasi inom din ako ng inom ng tubig maganda din daw kasi yun para sa akin.”

4. Activity – ExercisePattern

“Hindi ako nageehersisyo sa bahay, hindi ko kasi iyon nakasanayan. Nakakapaglakad-lakad ako kapagbibili ako ng pandesal sa labasan naming pang almusal.”

Ngayong naospital ako natutunan ko na ang kahalagahan ng pageehersisyo kahit siguro paglalakad araw-araw. Natatakot kasi ako subukan na magjogging kasi bka lalo bumuka etong tahi ko sa tyan.”

The client became aware of the importance of exercise for his health upon hospitalization and planned to practice that at home. His hospitalization helped him realize the significance of exercise to his health.

5. Sexuality – Reproductive Pattern

Patient refused to give/share information Client is not open to talk about his Sexual and reproductive pattern because for him it should be private between him and his wife.

6. Sleep – Rest Pattern “Sa bahay naming maaga talaga kaming natutulog, alas otso o alas nwebe natutulog na talaga ako.”

“Hirap akong matulog dito sa ospital, sa gabi halos tatlong oras nga lang ang tulog ko kasi pagising-gising ako. Naninibago siguro ako. Pero merong pinapainom na gamut sa akin na nakakaantok. Pag iniinom ko yun kahit tanghaling tapt inaantok ako.

Sleep and rest pattern of the patient was altered upon hospitalization due change in the environment. The medications that he I taking also affects his sleeping pattern. Diphenhydramine is one of his medications and one common side effect of this is sleepiness.

7. Cognitive –Peceptual Pattern

“Di pa naman ako makakalimutin. Kilala

“Ewan ko ba, epekto siguro ng gamot,

The client is confused with regard to the time

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ko pa naman lahat ng kasama ko sa bahay.”

kailangan pa kasi ipaalala lage sakin ng misis ko na kailangan ko uminom ng gamut. Nalilito kasi ako sa mga angalan ng tabletas. Yung mga pangalan naman wala nagbago alam ko pa din ang pngalan ng mga anak ko.”

of medication. His cognitive pattern was also slightly affected, he denies this because for him he’s still able to recite his children’s names and remember thing that happened in the past but considering the question regarding his elimination pattern in the hospital. He already forgot the last day of his bowel elimination.

8. Role Relationship Pattern

“Maayos naman ang samahan namin ng asawa at mga anak ko. Nahihiya nga ako sa asawa ko at mas malaki ang kita nya kesa sa akin. Halos siya na nga ng nagtatrabaho para sa pamilya namin pero di namin pinag-aawayan yun. Bago ako maospital tulungan kme sa gastusin sa bahay.”

“Ngayong naospital ako alam ko na mas tumatag ang samahan naming ng asawa ko at nakita ko ang pagpapahalaga sakin ng mga anak ko. Nahihiya nga langako kasi nagging pabigat pa ako dahil kailangan pa nila akong bantayan dito sa ospital at hindi ako makatulong sa pinansyal dahil di ako makapagtrabaho. May gawa pa naman kami sa construction ngayon.”

Prior to hospitalization the client has already a problem with regards to role pattern because he is guilty that his wife seems to be the bread winner of the family because of the small income that he contributes to the family and upon hospitalization his feeling of guilt upon his role worsen because supposibly he is working but due to his illness he can’t go to his work.

9. Self Perception / Self Concept Pattern

“Nung hindi pa ako ngakakasakit di ako madalas mag-alala sa sarili ko. Mas mahalaga yung pamilya ko. Sa katunayan nga kahit ngakakasakit ako pinipilit ko na

“Hindi naman ito ang unang beses na naospital ako, pero ngayon naisip ko na na kailangan ko alagaan ang sarili ko dahil tumatanda na din ako. Kung babalewalain ko

The client learns to appreciate his self and give importance to his health rather than the first time he has been hospitalized. He realized that he fulfilled he’s role as a father and

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makasideline sa trabaho para magkapera para sa pangastos namin. Madami na din mga pinagdaanan ko sa buhay. Alam ko naman na nagging makabuluhan buhay ko. Napagtapos ko ang mga anak ko kahit hayskul at napalaki ko sila ng maayos. Kahit construction worker lang ako araw-araw din naman kme nakakakain ng tatlong beses dahil sa pagtutulungan naming ng asawa ko”

ang sakit ko at lalong lalala nakakaawa naman ang pamilya ko. Mas lalo kong napatunayan na nagging mabuti akong padre de pamilya dahil di ako pinapabayaan ng asawa at mga anak ko dito sa ospital”

husband because his wife and sibling doesn’t leave him alone.

10. Coping Stress Tolerance Pattern

“Hindi naman ako madalas mapagod dahil contratahan lang naman ang trabaho ko. Pag may trabaho sa construction itinutulog ko nalang ang pagod ko o kya manonood ng TV.”

“Hindi naman ako napapagod dito kasi magdamag na nakahiga lang naman, naiinip na nga ako eh.Inaaliw ko nalang ang sarili ko sa pakikipagkwentuhan sa misis ko. Wala naman kasing TV ditto.”

The client has changed his way of coping but still prefer watching TV to relieve his stress.

11. Values – Belief Pattern

“Hindi ako palasimba na tao. Pero nagdadasal din naman ako. Hindi kami katulad ng ibang pamilya na sama-sama nagsisimba tuwing lingo kasi may pamilya na din yung dalawa kong anak. Naniniwala din ako sa mga albularyo, pag yata mahihirap dun una lumalapit”

“Sa paglabas ko siguro dito sa ospital e magsisimba na ako para makaagasalamat sa Diyos. Kung tutuusin kasi pang tatlong buhay ko na to kasi dib a naoperahan na ako. Eto pa din ako, buhay pa din. Patuloy pa din ang pagkonsulta ko sa albularyo. Wala naman masama kung maniwala

His belief in prayers and in God became stronger upon hospitalization. He also believe in herbularyos.

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ako e.”

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PHYSICAL ASSESSMENT

Date performed: January 28, 2013 No. of hospital Days: 4 days

1. Vital signs:a. Temperature: 37.9°Cb. Pulse Rate: 71 bpmc. Respiratory Rate: 24 cpmd. Blood pressure: 120 / 80 mmhg

2. Regional Examination: Regions of the body Methods of Assessment

(IPAP)Results

a. Hair Inspection / Palpation Evenly distributed hair, smooth, without dandruff, black in color, no infection or infestation of parasite.

b. Head Inspection / Palpation Rounded and smooth, no wounds, (-) masses

c. Face Inspection / Palpation Symmetrical in shape, centered head position

d. Eyes Inspection / Palpation Symmetrical, eyelashes are evenly distributed and pale conjunctiva, yellowish sclera, PERRLA.

e. Nose Inspection / Palpation (+) mucus discharge, able to smell, no lesion, no nasal flaring.

f. Mouth and pharynx Inspection Gums: slightly reddish in color, wearing full dentures up and down, pinkish tongue, (-) swelling throat.

g. Neck Inspection / Palpation No masses present, flexible and movement of the head equally both sides, supported by pillows.

h. Chest wall ( Anterior) Inspection / Palpation / Auscultation

Symmetric, (-) fractures, heart rate heard at mid clavicular space at 4th intercostals space (71bpm), (+) crackles

i. Chest wall (Posterior) Inspection / Palpation / Auscultation

(-) fracture, spine is aligned, uses of accessory muscle like scalene when breathing.

j. Breast and Axilla No assessment done. No assessment done.

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k. Heart Auscultation (-) arrythmiasl. Abdomen Inspection

(patient refused to auscultate, percuss

andpalpate his stomach due to pain)

Rounded, bloated, shiny, (+)evidence of enlargement of liver, 6inches scar on right quadrant of the stomach noted, penrose drainage noted at right quadrant of the stomach, hair is well distributed.

m. Skin and nails Inspection Skin: jaundice complexion, evenly distributed hair on extremities, presence of sweat at times.Nails: yellowish nail bed, thick, hard, roundedCapillary Refill: 2-3 secs.

n. Anus and Rectum No assessment done. No assessment done.o. Extremities (lower) *include ROM and muscle strength

Inspection Warm to touch, wasn’t able to freely move lower extremities due to radiating pain from the abdomen

p. Extremities (upper) *include ROM and muscle strength

Inspection Warm to touch, wasn’t able to freely move upper extremities due to radiating pain from the abdomen

q. Urinary Inspection Dark orange urine, no foul odor

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LABORATORY STUDIES/DIAGNOSTIC STUDIES

BLOOD CHEMISTRY

TEST NAME RESULT INTERPRETATION NORMAL RANGE ANALYSIS

HDL CHOLESTEROL 0.187 1.03-1.55 mmol/L carry cholesterol through the blood

AMYLASE57.1 NORMAL 20-110U/L

CHOLESTEROL 3.57 NORMAL 3.5-5.7mmol/l

GLUCOSE 5.19 NORMAL 3.9-5.22mmol/l

TRIGLYCERIDES 1.58 NORMAL 0.5-1.04mmol/

TEST NAME RESULT INTERPRETATION NORMAL RANGE ANALYSIS

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DIRECT BILIRUBIN

108.9 3.4-13.8 umol/l Conjugated bilirubin is another name for direct bilirubin.Bilirubin concentrations are elevated in the blood either by increased production, decreased conjugation, and decreased secretion by the liver, or blockage of the bile ducts. In cases of increased production, or decreased conjugation, the unconjugated or indirect form of bilirubin will be elevated.

INDIRECT BILIRUBIN

113.1 0-10umol/l Unconjugated bilirubin is another name for indirect bilirubin

SGOTSerum glutamic oxaloacetic transaminase or Aspartate transaminase (AST)

49.26 9-48u/l Serum glutamic oxaloacetic transaminase, an enzyme that is normally present in liver and heart cells. SGOT is released into blood when the liver is damaged. The blood SGOT levels are thus elevated with liver damage

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SGPTtransaminase (ALT), also called Serum Glutamic Pyruvate Transaminase (SGPT)

51 5-49u/l The blood SGPT levels are thus elevated with liver damage. Elevations of SGPT, an enzyme found within the liver cells, indicate that the liver cells are either leaky (internal contents are entering the blood) or damaged.

TOTAL BILIRUBIN 222 8.5-23.6umol/l total bilirubin measure both unconjugated and conjugated bilirubin, and are performed to evaluate jaundice. anemia, various liver diseases (including hepatitis), and impaired bile excretion.

AMYLASE 42.1 NORMAL 20-110u/l

TEST NAME RESULT INTERPRETATION NORMAL RANGE ANALYSIS

Hemoglobin 111 120-170g/l The hemoglobin molecules with the help of external chemical factors take up oxygen molecules in the lungs

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and then send them to the various tissues of our body.

Hematocrit 0.339 0.40-0.57 Hematocrit is the measure of how many red blood cells there are in the blood. This number is tested by taking a sample of blood. The result is given as a percentage.

RBC 3.27 4.5-6.0 The main function of the red blood cell is to transport oxygen from the lungs, to the other tissues and cells of the body

Lympocytes 0.164 0.20-0.40 A lymphocyte is a type of white blood cell present in the blood. White blood cells help protect the body against diseases and fight infections.

MCHC(mean corpuscular hemoglobin concentration)

32.6 33.0-37.0 Mean corpuscular hemoglobin concentration (MCHC) is the average concentration of hemoglobin in red blood cells. MCHC is used to help diagnose the type (cause) and severity of anemia.

WBC 26.3 4.6-10 They fight infections in a process known as ‘phagocytosis’ where they surround the foreign organisms and destroy it.

SEGMENTERS 0.779 0.50-0.70 it means that theres a presence of

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infectionSegmenters (segmented neutrophils, are one of the types of neutrophils, which are the most common type of white blood cells.

DIAGNOSTIC EXAMCHEST PA

RESULT:NO ACTIVE PARECHYMIAL INFILTRATESHEART IS NOT ENLARGEDBLUNTED RIGHT COSTOPHRENIC SULCI

IMPRESSION: PLEURAL THICKENING VS MINIMAL PLEURAL EFFUSION, RIGHT.

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DRUG ORDER MECHANISM OF ACTION

INDICATIONS CONTRAINDICATIONS

ADVERSE EFFECTS OF THE DRUG

NURSING RESPONSIBILITIES/

PRECAUTIONS

Generic name:Metronidazole

Brand name:MetronidazoleBenzoate

Classification:Antibacterial, antiprotozoal

Dosage:500mg/vial1vial every 8hrs.TIV

ANST(-)

A nitroimidazole derivative that disrupts bacterial and protozoal DNA, inhibiting nucleic acid synthesis.

Therapeutic Effect: Produces bactericidal, antiprotozoal, amebicidal, and trichomonacidal effects. Produces anti-inflammatory and immunosuppressive effects when applied topically.

For treatment of anaerobic infection (skin and skin structures, lower respiratory tract.

Hypersensitivity to other nitroimidazole derivatives.

Peripheral neuropathy, manifested as numbness and tingling in hands or feet, is usually reversible if treatment is stopped immediately after neurologic symptoms appear. Seizures occur ocassionally.

Check the prescribed medication for 3 time on the first encounter, before and after withdrawing the medR> so that the medicine is properly checked according to the doctor’s prescription.

Give first health teaching before giving the patient.R> to make the patient prepare and know what to expect

The med should be given in IVT route according to the doctorR> Follow the doctor’s order.

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Question for hypersensitivity on metronidazoleR> to determine if the med is applicable to patient.

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DRUG ORDER MECHANISM OF ACTION INDICATIONS CONTRAINDICATIONS ADVERSE EFFECTS OF THE DRUG

NURSING RESPONSIBILITIES/

PRECAUTIONS

Generic name:Ciprofloxacin hydrochloride

Brand name:Ciloxan

Classification: Anti-infective

Dosage:500mg/tab1tab BID

inhibits the enzyme DNA gyrase in susceptible bacteria, interfering with bacterial cell replication.

Therapeutic Effect:Bactericidal

For treatment of infections due to, S. typhi including intra-abdominal, and lower respiratory tract.

Cautions: renal impairment, CNS disorders, seizures, those taking caffiene.

Superinfection, cardiopulmonary arrest, chest pain, and cerebral thrombosis may occur. Hypersensitivity reaction, including photosensitivity (as evidenced by rash, pruritus, blisters, edema and burning skin) have occurred in patients receiving fluoronolones.

Question for hypersensitivity for the medicineR> since it will harm the patient

Monitor for any dizziness, headache, visual changes, tremors.R> to determine client’s response to the med.

Do not take with antacidsR> since it could reduce or destroy the drug’s effectiveness.

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Dug Name Mechanism of Action Indication Contraindication Adverse Effects Nursing Interventions

Generic Name:

Mupirocin ointment

>Bactroban

Drug Classification:

AntibacterialTopical

Dosage:Apply in wound site RUD every 8hrs.

It kills sensitive bacteria by stopping the production of essential proteins needed by the bacteria to survive.

Traumatic skin lesions infected with staphylococcus aureus or pyogenes

allergic to any ingredient in Mupirocin Ointment

>Burning

>pain

>stinging

>Severe allergic reactions (rash; hives; itching;

-rash>severe itching

Mupirocin Ointment is for external use only. Do not get it in your eyes or mouth.

Long-term or repeated use of Mupirocin Ointment may cause a second infection.

Apply a small amount of Mupirocin Ointment 3 times a day.

Wash and completely dry the affected area. Gently rub the medicine in until it is evenly distributed.

The affected area may be covered

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with gauze or a bandage.

To clear up your infection completely, use Mupirocin Ointment for the full course of treatment. Keep using it even if you feel better in a few days.

Wash your hands immediately after using Mupirocin Ointment.

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Dug Name Indication Mechanism of Action Side Effects/ Adverse Effects

Nursing Considerations

Generic Name:ceftriaxone

Brand Name:Forgram

Classification:Cephalosporins

Dosage:1gram/vial2vialsODTIV

INDICATIONS:Treatment of infections of the lower resp tract, skin & skin structure infection, intra-abdominal infections.

Inhibits cell-wall synthesis,promoting osmotic instability;BACTERIACIDAL.

Pain Phlebitis Rash Diarrhea Thrombocytosis Leucopenia Respiratory

superinfections

Assess patient’s previous sensitivity reaction to penicillin or other cephalosphorins. Assess patient for

signs and symptoms of infection before and during the treatment Obtain C&S before

beginning drug therapy to identify if correct treatment has been initiated. Assess for allergic

reaction. Assess for possible

superinfection: itching fever, malaise, redness, diarhhea

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Medication Classification/Action Indications Contraindications Side Effects Adverse Effects Nursing Responsibilities

GENERIC NAME:DiphenhydramineHydrochloride

BRAND NAME:Benadryl ®

USUAL DOSAGE/ FREQUENCY:1 Ampule NowTIVDATE:1/28/13

Classification: Anti-histamine Anti-motion

sickness

Action: Competitively blocks the effects of histamine at H1 receptor-sites, has atropine –like, anti-pruritic and sedative effects.

Relief of allergic symptoms

Night

time sleep aid

Active and prophylactic treatment of motion sickness

Cough due to colds.

Contraindicated with allergy or hypersensitivity to any anti-histamines, third trimester of pregnancy and lactation.

Use cautiously with narrow-angled glaucoma, stenosing peptic ulcer, prostatic hypertrophy, asthmatic attack, bladder neck obstruction, pyloroduodenal obstruction.

Drowsiness, sedation, disturbed coordination

headache & dizziness constipation

epigastric distress

thickening of bronchial secretions

palpitations dryness of

nasal mucosa

anaphylactic shock

Assess the patient for any history of allergy to the drug, certain medical condition and history that may affect the potency or even produce opposite effect when given. Administer with food if epigastric discomfort occurs. Monitor patient’s response and arrange for adjustment of dosage to lowest possible effective dose.Instruct patient to avoid the use of

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alcohol, serious sedation may occur.hallucinations, tremors, loss of coordination, unusual bleeding or bruising, visual disturbances and irregular heart beats.

DRUG CLASSIFICATION ACTION DOSAGE INDICATION CONTRAINDICATION ADVERSE REACTION

NURSING RESPONSIBILITY

Generic Name: Hydroxyzine

Brand names: Atarax

First Generation Anti-Histamine

Hydroxyzine reduces activity in the central nervous system. It also acts as an antihistamine that reduces the natural chemical

10mg /tabGive 1tab now.Date:1/31/13

Hydroxyzine is also used to treat allergic skin reactions such as hives or contact dermatitis.Hydroxyzine is used as a sedative to treat anxiety and tension.

Contraindicated in patients hypersensitive to drug

Hydroxyzine can cause side effects that may impair your thinking or reactions. Be careful if you drive or do anything that requires you to be

Take this medicine with a full glass of water.Seek emergency medical attention if you think you have used too much of this medicine.Overdose symptoms may include extreme

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histamine in the body. Histamine can produce symptoms of sneezing and runny nose, or hives on the skin.

Hydroxyzine may also be used to control nausea and vomiting.

awake and alert. Stop using hydroxyzine and call your doctor at once if you have a serious side effect such as tremors, confusion, seizures, or restless muscle movements in your eyes, tongue, jaw, or neck. Avoid drinking alcohol. It can increase some of the side effects of hydroxyzine.

drowsiness, nausea, vomiting.

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DRUG CLASSIFICATION ACTION DOSAGE INDICATION CONTRAINDICATION ADVERSE REACTION

NURSING RESPONSIBILITY

Generic Name:Paracetamol

Brand Name:Biogesic

It belongs to a class of drugs antipyretics (fever reducers).

It. It reduces fever through its action on the heat-regulating center of the brain. Specifically, it tells the center to lower the body's temperature when the temperature is elevated.

1tab every 4hrs.For temperature 37.7/cAnd up.

It is used to bring down a high temperature (fever)

Contraindicated Hypersensitivity to drug

Use cautiously in patients with any type of liver dse.

Side effects are Skin rashes, blood disorders and acute inflammation of the pancreas have occasionally occurred in people taking the drug on a regular basis for a long time.

Assessment & Drug Effect:Monitor for S&S of: hepatotoxicity, even with moderate acetaminophen doses, especially in individuals with poor nutrition.

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ANATOMY AND PHYSIOLOGY

ANATOMY OF THE LIVERThe liver is the largest organ in the body, normally weighing about 1.5kg (although this can increase to over 10kg in chronic cirrhosis). The liver is the main organ of metabolism and energy production; its other main functions include:

Bile production Storage of iron, vitamins and trace elements

detoxification

conversion of waste products for excretion by the kidneys

Gross AnatomyThe liver is divided into 4 lobes:

1. Right2. Left3. Caudate4. Quadrate

Falciform ligament separates the right and left lobes. Round ligament-inferior to the falciform ligament which protrudes from the liver slightly Gallbladder- most inferior portion of the right lobe Caudate lobe is located superiorly,approximately between the right and left lobes Sulcus for the inferior vena cava - Adjacent to the caudate lobe Portahepatis, where the hepatic artery and hepatic portal vein enter the liver Portal vein carries nutrient laden blood from the digestive system. Hepatic artery distributes blood to the liver, pancreas and gallbladder as well as to the

stomach and duodenal portion of the small intestine. Hepatic vein, where post-processed blood leaves the liver, is found inferior and adjacent to

the sulcus for the inferior vena cava. Bile duct which leads back to the gallbladder.

Microscopic

The basic functional unit of the liver is the liver lobule. The primary structures in a lobule include:

Plates of hepatocytes form the bulk of the lobule Portal triads at each corner of hexagon Central vein Liver sinusoids that run from the central vein to the portal triads Hepatic macrophages (Kupffer cells) Bile canaliculi (“little canals”) – formed between walls of adjacent hepatocytes Space of Disse – a small space between the sinusoids and the hepatocytes

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Cell Types

1. Hepatocytes Blood flowing toward the hepatic vein within the space of Disse passes both exposed surface areas of the hepatocyte plates, and toxins and nutrients within the blood are extracted by the hepatocytes.

2. Kupffercells are macrophages that reside in the sinusoids. These cells help clear out old red blood cells and bacteria. They also break down heme (the iron-containing pigment in hemoglobin) into bilirubin, which then becomes one of the chief pigments of bile.

3. Sinusoidal endothelial cells are fenestrated (Latin for “windows”), meaning they have large pores that allow most proteins to pass freely through the sinusoidal endothelium into the space of Disse, where they can make direct contact with hepatocytes. The pores are also bi-directional, meaning that proteins created by the liver and other substances stored or processed by the liver can also be passed back into the blood.

4. Ito cells are found in the space of Disse. They are important because when the liver is injured, the Ito cells transform into cells that produce collagen, which leads to liver fibrosis. If this occurs on a large scale, it can lead to cirrhosis of the liver.

5. Bile duct epithelial cells line the interlobular bile ducts within the portal triads.

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Pathophysiology

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Precipitating Factors: Chronic Alcoholic Tropical Areas Poor sanitation Male

Predisposing Factors: Pet/ Animal in home Homosexual ( Anal-

oral transmission) Swimming Migrants/travelers

from endemic area

Entamoebahistolytica cyst might ingested

Trophozite survives acidic stomach

Attachment to cecal mucosa and penetration of epithelium by lytic digestion

Invades to mesentery toward portahepatis

CC: Severe stomach pain and vomiting

Jaundice

SGOT 49.26/9-48u/lSGPT 51/5-49u/l

RBC 3.27/4.5-6.0

Hepatic Tissue Injury

Dolor (Pain)RUQ

- Diversion- Deep breathing exercise

Kupffer cells & more leukocytes attacked the invading trophozite

- Paracetamol- TSB

WBC 26.3/4.6-10

Pyrogen release

Hypothalamus

T 37.9 C

Pus Formation

- Penrose drainage

Hepatic Abscess Pus from

liver might spread to lungs

Pleural thickening vs minimal pleural effusion,right

Shortness of breath

- Ciprofloxacin- Ceftriaxone

Postcholecystectomy

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Unable to conjugate and excrete bilirubin

Back up to liver and reabsorbed into blood circulation

Jaundice and Icteric Sclera

Itching

- Diphenhydramin- hydroxyzine

Direct Bilirubin 108.9/3.4-13.8 umol/lIndirect Bilirubin 113.1/0-10 umol/lTotal Bilirubin 222/8.5-23.6 umol/l

Bile salt unable to secrete

Histamine Release

Vasodilate

Rubor/Redness

Alternate hot and cold compres

Actual Nursing Care PlanAssessment Diagnosis Planning Implementation Evaluation

Intervention RationaleSubjective Data:“Mainit ang pakiramdam ko” as verbalized by the patient

Objective Data:• Core Temperature of 37.9 degree Celsius • Resiratory Rate of 24 cpm• Flushed and warm skin

Hyperthermia related to infection as evidenced by core temperature of 37.9 degree celcius, RR of 24 cm and flushed and warm skin.

SHORT TERM GOAL:

Within 1 hr of nursing intervention patient will decrease his body temperature to 37.2 degree Celsius

Independent:

• Promote surface cooling by means of cool tepid sponge bath especially in groin and axilla

•Maintain bed rest

• Increase fluid intake

•Provide cool clothing

• Monitor vital signs:

-BP

• To restore normal body temperature by means of heat loss by evaporation and conduction

• To reduce metabolic demands

•Decrease in fluid intake may cause dehydration

•To enhance body temperature

•To prevent further complication

-Central hypertension or peripheral/postural hypotension can occur.

After 1 hr of nursing intervention patient’s body temperature became 37.4 degree Celsius

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-RR

-Temp

-Heart Rate

Dependent:• Administer antipyretics as indicated

•Administer medication such as antibiotics

-Hyperventilation may initially be present, but ventilator effort may eventually be impaired by seizures and hyper metabolic state.

-To prevent further increase in temperature that may lead to seizure and shock

-Dysrhythmias are common due to hyperthermia on blood and cardiac tissues

• To reduce increased body temperature

•To treat underlying cause for infection

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Collaborative:•Provide health teaching regarding the importance of adequate fluid intake

•To prevent dehydration

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Risk Nursing Care PlanAssessment Diagnosis Planning Implementation Evaluation

Intervention RationaleSubjective Data:“Nahihirapan ako kumilos kasi masakit ang tyan ko” as verbalized by the patient

Objective Data:• Abnormal Heart Rate•Dysrythmias•Sudden change in BP

Risk for Activity Intolerance related to pain

SHORT TERM GOAL:

Within 4 hrs or nursing intervention patient will identify and participate alternative ways to maintain desired activity level

Independent:

• Evaluate current degree of deficit in light of usual status

•Adjust activities (reduce intensity level or discontinue activities that cause undesired physiologic changes)

•Provide rest periods between activities

•Promote comfort measures and provide for relief of pain

•Provide positive atmosphere while acknowledging difficulty of situation for the client

• To provide comparative baseline

•To prevent over exertion

•To reduce fatigue

•To enhance ability to participate in activities

•Help to minimize frustration and rechannel energy

After 4 hrs of nursing intervention patient identified and participated alternative ways to maintain desired activity level

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Dependent:•Assist with activities

Collaborative:•Refer appropriate sources for assistance or equipment as needed

•To protect client from injury

•To sustain activity level

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Wellness Nursing Care PlanAssessment Diagnosis Planning Implementation Evaluation

Intervention Rationale“Nihihiya nga ako sa asawa ko dahil di na ako nakakapagbigay ng pero tapos nagging pabigat pa ako dahil kailangan nya pa akong bantayan dito sa ospital, pero ganun talaga kailangan ko muna tumigil dito, babawi nalang ako sa kanya pag lumakas na ako, ako naman ang magtatrabaho ” as verbalized by the patient

Objective Data:•Respect for family members are evident•Family roles are flexible and appropriate for developmental stages

Readiness for enhanced family processes

SHORT TERM GOAL:

Within 2 hrs of nursing intervention patient will demonstrate individual involvement in problem solving to improve family communications

•Establish Stress importance of continuous, open dialog between family members

•Assist family to identify and encourage use of previously successful coping behaviors

•Encourage participation in learning role-reversal activities

•Provide educational materials and information

•Facilitates ongoing expression of open, honest feelings and opinion and effective problem solving

•Promotes recognition of previous success and confidence in own abilities to learn and improve family interactions

•Help individuals to gain insight and understanding of other persons feelings and point of view

•Enhances learning to assist in developing relationship among family members

After 2 hrs or nursing intervention patient demonstrated individual involvement in problem solving to improve family communications

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EVALUATION

The student nurses are proud to pronounce that we were able to meet the objectives we set

which are the following:

1. For the participants/critics, for us presenters & significant others to have a better understanding on the disease process.

2. To have the pathophysiology and to trace the occurrence of Liver abscess.3. To utilize properly the nursing process (assessment, diagnosis, planning,

intervention, evaluation) as the framework for the care of the patient. 4. To learn various medications, its condition, adverse effects & accompanying

nursing responsibilities. 5. To put into action what we have learned in the school (such as nursing process)

and apply our knowledge in providing quality and individualized nursing care. 6. To enhance group’s attitude, like discipline, cooperation, leadership abilities and

teamwork in making and presenting a case presentation.

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