Case Study #2
Mr. Scottaline
History of Presenting Illness (HPI)
Mr. Scottaline is a 58-year-old male who was brought in to the emergency department by EMS. His neighbor called EMS on his behalf because he looked generally unwell, jaundiced, lethargic, and was behaving in a confused manner.
Health History
AUD (alcohol use disorder)
Non- smoker
Known Liver Cirrhosis with portal hypertension
Depression
Family history is unremarkable
Home Medications
Carvedilol 6.25mg PO daily
Folic Acid 5 mg PO daily
Multivitamins 1 Tab PO daily
Paroxetine 40 mg PO daily
Spironolactone 25 mg PO daily
Thiamine 100 mg PO daily
Physical Assessment on Admission Day 1
General Appearance: disheveled, slow and unsteady gait
Neurological: lethargic, oriented to person, inconsistent with date and time
Respiratory: clear air entry to all lung fields, no SOB, no cyanosis, respirations unlaboured
Cardiovascular: S1 S2 heard, no murmur, pulses moderate, regular and palpable, skin warm, dry. Cap refill <3 seconds, +2 edema to lower legs bilaterally
Gastrointestinal: Abdomen large, softly distended, mild diffuse tenderness, BS x4, loose BM x2 today loose
Genitourinary: Voiding without difficulty, urine clear yellow. No bladder distention noted
Integumentary/ Musculoskeletal: Skin intact, jaundiced skin & sclera, a few scattered bruises to arms and legs. Motor power moderate and equal x4.
Psychosocial: Lives alone, no kids, divorced. Retired factory worker. Poor management of cirrhosis and portal hypertension. Currently has ETOH consumption ~8beers/day.
Vital Signs: T. 37.8, HR 96 regular, RR 18, 96% RA, BP 94/60
Diagnostics
CT scan demonstrates worsening liver cirrhosis
Abdominal U/S demonstrates significant Ascites
Ascites fluid diagnostics demonstrate spontaneous bacterial peritonitis
Endoscopy demonstrates increased portal hypertension
Blood Work on Admission
CBC: Hemoglobin 130 g/L (120-160), Platelets 90 (130-380), WBC 13.2 (3.5-10.5)
Electrolytes: Sodium 136 mEq/L (135-145), Potassium 3.8 mEq/L (3.5-5.0), Chloride 100 mEq/L (98-107), magnesium 0.82mmol/L (0.74-1.07)
Renal panel: Creatine 187 (53-106mcmol/L) , eGFR 26 ml/min (>60 ml/min)
Liver panel: AST 68 U/L (0-35), ALT 55 (4-36), ALP 225 (35-120 U/L), Total Bilirubin 32 mcmol/L(5.1-17)
Miscellaneous: ammonia 77 mcmol/L (6-47 mcmol/L), albumin 22 g/L (35-50 g/L), INR 1.9 (0.9-1.1)
Working Diagnosis
Hepatic encephalopathy
Spontaneous bacterial peritonitis (SPB)
Query onset of Hepatorenal syndrome
Significant progression of liver cirrhosis and portal hypertension
Alcohol withdrawal
In-Hospital Treatment & Orders
Paracentesis drained 3L fluid
CIWA protocol
Delirium and CAM (confused assessment method) monitoring
Monitoring and replacement of electrolytes
Monitoring of refeeding syndrome
In-Hospital Medication Orders
Albumin IV 25% x3 doses
Baclofen 5mg TID (*new)
Ceftriaxone 2g daily x5 days for SPB
Carvedilol 6.25 mg PO daily (discontinued)
Diazepam 10mg IV/PO Q1H PRN for CIWA scores 10-19 until scores less than 10.
Folic Acid 5 mg PO daily
KCL 10mmol IVPB x3 doses
Lactulose 30ml QID- titrate to 3-4 BM’s /day (*New)
Multivitamins 1 Tab PO daily
Paroxetine 40 mg PO daily
Rifaximin 55mg PO BID (*new)
Spironolactone 50 mg PO daily (*New dose)
Thiamine 100 mg PO daily
Day 2 Vitals and Blood Work
CBC: Hemoglobin 126 g/L (120-160), Platelets 90 (130-380), WBC 12.4 (3.5-10.5)
Electrolytes: Sodium 132 mEq/L (135-145), Potassium 3.3 mEq/L (3.5-5.0), Chloride 100 mEq/L (98-107), magnesium 0.69mmol/L (0.74-1.07)
Renal panel: Creatine 190 (53-106mcmol/L) , eGFR 25 ml/min (>60 ml/min)
Vital Signs: T. 36.8, HR 92 regular, RR 18, 96% RA, BP 102/74
Mr. Scottaline is having a complicated and likely an extended hospital stay for end-stage liver cirrhosis. His complications have included moderate alcohol withdrawal, electrolyte imbalances, refeeding syndrome, delirium, skin breakdown from edema and frequent diarrhea, hypotension, and deconditioned mobility.
As his nurse on day 2, you need to prioritize his needs, create a plan of care, and demonstrate understanding of how all of these health concepts are related.
Concept Map and Nursing Care Plan
For assignment 2 concept map and case analysis you are the RN in charge of Mr. Scottaline’s care and you want to develop a nursing care plan to provide direction for his acute priority needs. Use the assessment data and information in the case scenario to guide your development of the one-page only concept map visual diagram. Identify and outline 6-10 nursing care priorities related to this case scenario and number the care priorities in level of importance. Include lines and arrows to visually display relationships and connections among concepts. Include linking words with the lines to indicate the nature of the connection or relationship (for example: leads to, influences, contributes to, results in, etc.)
Include a full nursing care plan (nursing diagnosis, SMART goals, nursing interventions supported with credible and current sources of evidence, and evaluation statements) with the first nursing care priority you have identified. This can be completed as an appendix attached to the paper portion of the assignment. Refer to the Assignment 1 and 2 marking guide in the Assessment Overview for further direction of the requirements of the concept map as well as case analysis. You may also find it useful to go back to Unit 1 and review the content related to Concept Mapping. Keep in mind the concept map in Unit 1 is not as fully detailed as we expect your concept map to be. The concept map is worth 65% of your entire mark for this assignment, so spend your time constructing this.
Choose three questions from the case analysis list below that correlate to your learning needs. Ensure that you are adequately integrating the case of Mr. Scottaline into your discussion. Answers for each question are limited to 250 – 400 words (per question) and you are expected to use credible and current sources of evidence to support your discussion. Please refer to the Using Evidence in Scholarly Writing document in the References & Help section of the course homepage. The case analysis discussion must also be written in APA formatting and citation style, you do not need to include and intro or conclusion.
Describe one effect of late-stage cirrhosis on each of the following systems: central nervous system, hematologic, integumentary, hepatic, and renal.
Explain the pharmacokinetics and pharmacodynamics of the medications rifamixin and baclofen. Why was Mr. Scottaline prescribed these?
Discuss the pathophysiology of edema in Mr. Scottaline lower extremities and three nursing interventions.
Why was Mr. Scottaline prescribed thiamine, folic acid, and multi vitamins?
Describe the relationship between AUD, hepatic encephalopathy, ascites and SPB.
What are three priority nursing interventions post abdominal paracentesis? Explain the use of albumin in this case scenario.
Mr. Scottaline is experiencing frequent diarrhea. What lab values would you anticipate to be abnormal and why? Would you stop his lactulose? Why or why not?
Explain the importance of monitoring alcohol withdrawal symptoms. Why are benzodiazepines used to treat withdrawal symptoms?
Explain electrolyte imbalances and refeeding syndrome in this case study.
You are planning to engage with Mr. Scottaline regarding health promotion strategies and addressing barriers to discharge. Discuss three health promotion teaching focuses for Mr. Scottaline. Which allied members of the health care team you would consult in preparation for discharge?
Resources Used
Alberta Health Services. (2015). Alcohol withdrawal protocol- adult inpatients; self-directed learning module and self-quiz. Retrieved from Alcohol Withdrawal Treatment Protocol (albertahealthservices.ca)
American Association for the Study of Liver Diseases. (2021). Practice guidelines. Retrieved from https://www.aasld.org/publications/practice-guidelines
Civan, J. M. (2019). Cirrhosis. Merck Manuals. Retrieved from https://www.merckmanuals.com/professional/hepatic-and-biliary-disorders/fibrosis-and-cirrhosis/cirrhosis?query=cirrhosis
Crabb, D.W., Im, G.Y., Szabo, G., Melliger, J.L., Lucey, M.R. (2019). Diagnosis and treatment of alcohol‐associated liver diseases: 2019 Practice guidance from the American Association for the Study of Liver Diseases. Hepatology Vol 71 (1) pp 306-333 https://aasldpubs.onlinelibrary.wiley.com/doi/full/10.1002/hep.30866 https://doi.org/10.1002/hep.30866
Pagana, K. D., Pagana, T.J, Pike-MacDonald, S.A. (2013). Mosby’s manual of diagnostic and laboratory tests. 1st Canadian Ed. Elsevier
Toy, E., Patland, J., & Warner, M. (2017). Case files internal medicine 5th ed. McGraw-Hill Education
Tholey, D. (2012). Portal hypertension. Merck Manuals. Retrieved from https://www.merckmanuals.com/professional/hepatic-and-biliary-disorders/approach-to-the-patient-with-liver-disease/portal-hypertension?query=portal%20hypertension
Tholey, D. (2021). Ascites. Merck Manuals. Retrieved from https://www.merckmanuals.com/en-ca/professional/hepatic-and-biliary-disorders/approach-to-the-patient-with-liver-disease/ascites?query=Ascites
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