HSNS270 Murray Cirrhosis Case Study Sample

• Subject Code : HSNS270
• University : University of New England My Assignment Services is not sponsored or endorsed by this college or university.
• Subject Name : Nursing

Introduction to Integrated Nursing Practice

Cirrhosis is the long term damage of the liver caused by the replacement of the normal liver tissue by scar tissue and develops typically over months or years. The aim of the current study is to analyse the health situation of Murray who is diagnosed with liver cirrhosis and admitted after seeing blood while vomiting and suitable management plan will be developed with indication of possibly prescribed medications.

Integrated Nursing Practice - Question 1

Any condition related to recurrent and persistent damage of hepatocyte lead to fibrosis causing inflammation and scarring of hepatocytes. As mentioned by Osna, Donohue & Kharbanda (2017), liver cirrhosis can be characterized by irreversible scarring and fibrosis of the tissue of liver. This causes severe injury to the liver. This lever injury leads to losing of vitamin A by the stellate cells of parasinusoidal. These cells become activated by Kupffer cells and hepatocytes produced cytokines. After this, the stellate cell converts into myofbroblast-like cells that produce pro-inflammatory cytokines and collagen promoting tissue fibrosis and dame of hepatocytes.

In order to counteract the damage, the function of stellate cells alters from healing wounds to causing fibrosis on the hepatocytes that are injured. The central vein and the sinusoids are compressed by the collagen and it leads to build up pressure in the sinusoids which develops portal hypertension pushes the fluids peritoneal cavity that develops ascites. Flowing back of the bloods becomes inflated in the “spleen” that leads to congestive splenomegaly which causes from the obstruction of the outflow of venous from the spleen that increases red pulp. Congestion of red pulp leads to be fibrotic. This include palpable left upper quadrant abdominal mass (Cipolla et al., 2018). Due to poor muscle development or lack of growth in the muscles, the output appearance is rather thin of Murray. This is when the circulatory system starts shunting and blood is diverted from the liver that leads to portal systemic shunt leads to poor muscle development.

The oesophageal varices have lead Murray to demonstrate symptoms such as vomiting large amount of blood. Resistance is increased in the renal blood flow caused by renal vasoconstriction leading to low filtration that is responsible for hepatorenal failure which is the cause of symptoms such as nausea, abdominal discomfort and anorexia. As a result of failure of the conjugation function of the liver, extreme un-conjugated bilirubin accumulation Jaundice may take place.

The further assessments for Murray will include the assessment of fluid retention capacity, Screening for hepatocellular carcinoma and screening for covert HE. Bleeding from different parts of the body is also needed to be detected such as gums, skin and stools. There are also chances of hypo-albuminemia due to the inability of the liver to produce albumin; therefore, checking regular for the stability of albumin level is required (Gounden & Jialal, 2018). Searching for the coagulation issues lack of synthesis of the clotting factors may also arise along with hepatic pulmonary syndrome which is required to be assessed for the further decision making for Murray for treatment. Apart from that, an assessment of the cardio-vascular risk is also required to be conducted.

Integrated Nursing Practice - Question 2

The follow up care for Murray is highly essential as this will play a role in helping Murray to feel in control for transitioning back into the everyday lives. In order to stabilise the physical and mental health of Murray, the follow up care plan for a community nurse will include coordination of guidance, care and support to the patients even after the end of the addiction treatment. It is required to make Murray feel that they are under clinical supervision and will be leading everyday life, coordinated care and support is required to be provided to Murray for sustaining sobriety (Low et al., 2018). During the diagnosis and treatment process, the patient and family members of the patients may remain under pressure and become agitated. One of the major roles of the community nurse is to management of the stress experienced by providing adequate and coordinated health support to the patient. There are several co-morbidities associated with liver cirrhosis Murray going through such ascites and variceal bleeding. The role of the community nurse is to help Murray in following up these co-morbidities and ensuring that the client is visiting a specialist at the time he needs.

The results from the health assessments will help the community nurse in fulfilling the following up requirements. As mentioned by Gramaje Úrbez-Torres, & Sosnowski, (2018), one of the most important tasks under follow-up patient is controlling or eliminating the risks of developing further symptoms. The assessment results might help the nurse to warn Murray for avoiding particular types of meal and about specialised consultation. Particular attention is also required to be put into the aspects related to compensated cirrhosis, specifically, surveillance for gastroesophageal varices, influenza and others. Another role of the community nurse in the context of Murray’s case is to conduct nutritional counselling so that Murray can maintain a body weight along with calorie malnutrition and for avoiding protein diet. As the bilirubin level is high and Murray has jaundice of sclera and skin, it is also required to suggest for a special diet that will lower the symptoms of jaundice.

Another responsibility of the community nurse is providing health education to the patient and to his family. As mentioned by Cheema, Al-Aryan & Al-Hamid (2019), most of the cases of cirrhosis of lever patients initially are unable to seek clinical health care as they are unaware of the reason they are facing these health issues. Murray and his family members are required to be made aware of the complications associated with cirrhosis of liver so that they can avoid those by following healthy diet, reducing alcohol use and maintain a body weight. On the other hand, the whole process from admitting the patient to discharge, the family members may face mental stress due to lack of knowledge about the situation. Therefore, nurses are required to provide details about the prevention process in simple language so that patient and his family members can understand.

Integrated Nursing Practice - Question 3

In the case of Murray the risks associated with his diagnosis is increased drinking of alcohol. For instance, the patient may start drinking alcohol after the treatment is over. Though Murray was diagnosed twelve years ago with liver cirrhosis he did not control over drinking alcohol leading to the current situation. Other risk factors of liver cirrhosis include chronic hepatitis B caused by hepatitis B virus and it plays a highly essential role in scarring of the liver. This is mainly spread through infected body fluids such as blood, semen etc (Island, 2019). Hepatitis C is also a virus damages the liver of individuals that lead to permanent inflammation and cirrhosis in the liver. This can manifest by showing symptoms related to fatigue, loss of appetite and skin yellowing. There are also chances of having Fatty liver disease resulting in liver cirrhosis. It is also required to assess the patient with cirrhosis so that it can be identified that if the patient is having autoimmune hepatitis or primary sclerosing cholangitis.

Due to the diagnosis of cirrhosis of lever, Murray might have been facing issues such as inability to be involved in the family activities such as going for holidays or as simple as visiting a dinner invitation. This might create emotional stress upon the family members of Murray as well as Murray himself. Therefore, the purpose of life style modification is not only limited to prevent relapse of the symptoms associated with cirrhosis, but providing emotional support to the patient also.

Changing the diet of Murray is required to be modified first to reduce the impact of the same upon the liver of Murray (Künzler‐Heule et al., 2016). It is required to ensure that Murray quits drinking alcohol for which, he is required to be suggested to attend the alcohol consumption prevention programs. Some exercises such as walking, activities for strengthening of muscles which might reduce the chances of death due to liver cirrhosis. Murray will be suggested not be exposed with gasoline, paint fumes, diesel and other likewise things. He will also be suggested to go for a lever transplant if the physical condition of the patient is permissible for that.

In order to provide emotional support, the patient can be suggested to join support group develop for people diagnosed with alcoholic lever cirrhosis. The increased use of alcohol in the current case is might be the result of lack of information regarding the causes and consequences of the damages that drinking can cause (Morganstein & Ursano, 2020). On the other hand, seeing blood while vomiting can lead Murray to feel stressed and induce fear from the assumption of dying. All of these can be managed by providing Murray with mental support. The patient can be suggested to have small meals frequently and salt substance with no ammonium. The intake of caffeine will also require being restricted and excessive hot and cold foods. 

Murray can also be suggested to take regular mouth care before and after meals as patient is prone to sore and gum bleedings and bad taste in mouth has led to develop the symptom of anorexia. The laboratory studies are required to be read effectively such as level of serum glucose, ammonia and total protein to keep the symptoms under control. A regular visit to a dietician incorporating current treatment plan into diet might be suggested for further prevention of malnutrition.

Integrated Nursing Practice - Question 4

It can be anticipated that as Murray’s cirrhosis is alcohol related, he would be prescribed with some medication such as Disulfiram. Some antiviral medications might be prescribed such as corticosteroids such as Prednisone. Chelating Agents that would be prescribed include Penicillamine (). Apart from that, Medications to Treat the Complications of Cirrhosis Antibiotics will include Ofloxacin. Octreotide can be prescribed for treating bleeding from varices.

Disulfiram

Pharmacokinetics:

Complete absorption after administration of oral effects can b observed after 3 to 12 hours. It is considered as highly “lipid-soluble” along with “initial localization in adipose tissue. Oxidization is performed in liver and excreted through urine. 5% to 20% of it is eliminated through feces.

Pharmacodynamics:

Disulfiram inhibits aldehyde dehydrogenase irreversibly resulting in prevention of the alcohol oxidation at the end of stage of acetaldehyde. Through an interaction with the ingested alcohol it increases levels of acetaldehyde much higher than those are produced through metabolism of normal alcohol (Huang et al., 2016)). Acetaldehyde induces highly unpleasant reaction with consumptions of even very small amount of alcohol.

Penicillamine

Pharmacokinetics:

It is highly absorbable after oral administration and their effect is observable after 1 hour of intake. The medication is metabolized by the liver converting into inactive compounds. Approximately 50% of drug excreted through urine and rest is excreted through feces.

Pharmacodynamics:

After consumption, it manifests though Antirheumatic action through which it depresses “circulating IgM rheumatoid factor” and T cell activities. Some macroglobulins are also depolymerized by this drug. This develops stable and soluble complexes with lead, copper, mercury, iron, and other heavy metals (Li et al., 2019). These metals are excreted with urine.

Ofloxacin

Pharmacokinetics:

This drug is also well-absorbed after oral administration as its “bioavailability of Ofloxacin” is about 98%. This can be widely spread into tissues and fluids of the body. 70% to 80% of the single dose is excreted through urine and 10% is metabolized.

Pharmacodynamics:

With respect to synthesis of bacterial DNA, Ofloxacin impede with DNA gyrase. It spectrum of action includes “gram-positive and gram-negative aerobic bacteria”.

Octreotide

Pharmacokinetics:

Complete absorption after injection of the drug is ensured which them distributes to the plasma and binding is performed with serum lipoprotein and albumin. The elimination of the drug from the blood is slow and its effect can last from 1 hour to 12 hours. 35% of the drug is excreted through unchanged urine (Peterson et al., 2019).

Pharmacodynamics:

The naturally occurring somatostatin’s action is mimicked by Octreotide which leads to decrease in the gastroenterohepatic peptides which might take towards adverse effects.

Conclusion on Integrated Nursing Practice

In conclusion, it can be stated that Murray is required to be assessed further for the complete understanding of his current health condition and possible risk factors. The life style modification plan for Murray has included changes in diet plans, involving in cirrhosis support and intervention group, regular health check up and emotionally supported environment for faster recovery.

Reference List for Integrated Nursing Practice

Cheema, E., Al-Aryan, A., & Al-Hamid, A. (2019). Medicine use and medicine-related problems in patients with liver cirrhosis: a systematic review of quantitative and qualitative studies. European journal of clinical pharmacology, 1-12.

Cipolla, C., Florena, A. M., Ferrara, G., Di Gregorio, R., Unti, E., Giannone, A. G., ... & Pantuso, G. (2018). Sclerosing angiomatoid nodular transformation: laparoscopic splenectomy as therapeutic and diagnostic approach at the same time. Case reports in surgery, 2018.

Gounden, V., & Jialal, I. (2018). Hypoalbuminemia. In StatPearls [Internet]. StatPearls Publishing: USA.

Gramaje, D., Úrbez-Torres, J. R., & Sosnowski, M. R. (2018). Managing grapevine trunk diseases with respect to etiology and epidemiology: current strategies and future prospects. Plant disease, 102(1), 12-39.

Huang, J., Campian, J. L., Gujar, A. D., Tran, D. D., Lockhart, A. C., DeWees, T. A., ... & Kim, A. H. (2016). A phase I study to repurpose disulfiram in combination with temozolomide to treat newly diagnosed glioblastoma after chemoradiotherapy. Journal of neuro-oncology, 128(2), 259-266.

Island, P. E. (2019). Blood and Body Fluid Exposure Guideline. Blood, 2.

Künzler‐Heule, P., Beckmann, S., Mahrer‐Imhof, R., Semela, D., & Händler‐Schuster, D. (2016). Being an informal caregiver for a relative with liver cirrhosis and overt hepatic encephalopathy: a phenomenological study. Journal of clinical nursing, 25(17-18), 2559-2568.

Li, Y., Jiao, P., Li, Y., Gong, Y., Chen, X., & Sun, S. (2019). The synergistic antifungal effect and potential mechanism of D-penicillamine combined with fluconazole against Candida albicans. Frontiers in Microbiology, 10.

Low, J. T., Rohde, G., Pittordou, K., Candy, B., Davis, S., Marshall, A., & Stone, P. (2018). Supportive and palliative care in people with cirrhosis: International systematic review of the perspective of patients, family members and health professionals. Journal of Hepatology, 69(6), 1260-1273.

Morganstein, J. C., & Ursano, R. J. (2020). Ecological disasters and mental health: causes, consequences, and interventions. Frontiers in psychiatry, 11, 1.

Osna, N. A., Donohue Jr, T. M., & Kharbanda, K. K. (2017). Alcoholic liver disease: Pathogenesis and current management. Alcohol research: current reviews, 38(2), 147.

Peterson, B., Weyers, M., Steenekamp, J. H., Steyn, J. D., Gouws, C., & Hamman, J. H. (2019). Drug bioavailability enhancing agents of natural origin (bioenhancers) that modulate drug membrane permeation and pre-systemic metabolism. Pharmaceutics, 11(1), 33.

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