Video Case Study - Caring for Patients With Cirrhosis

Nurse Abigail works at a long-term care facility and is caring for Thomas, a 72-year-old male with a history of hyperlipidemia and obesity who was diagnosed with cirrhosis secondary to nonalcoholic fatty liver disease.

In collaboration with the registered nurse, RN Raashida, Nurse Abigail goes through the steps of the Clinical Judgment Measurement Model to make clinical decisions about Thomas’ care by recognizing and analyzing cues, prioritizing hypotheses, generating solutions, taking action, and evaluating outcomes.

First, Nurse Abigail recognizes important cues, including Thomas’ vital signs, which are temperature 98.8 F or 37 C, heart rate 98 beats per minute, respirations 20 breaths per minute, blood pressure 106/68 mmHg, and oxygen saturation 97 percent on room air.

Nurse Abigail notes his sclera and skin are jaundiced, or yellow-tinged; he has scattered petechiae, which are small, reddish-purple spots that occur because of bleeding from tiny blood vessels underneath the skin; and his abdomen is round and distended with fluid from a condition called ascites.

When asked to turn during his bed bath, Thomas becomes fatigued and short of breath. Next, Nurse Abigail analyzes these cues.

She reviews the electronic health record, or EHR, and notes that Thomas has gained 9 pounds since his weight was last taken, approximately one week ago.

She also sees that Thomas was seen by the physical therapist last week but refused treatment. Nurse Abigail knows that cirrhosis is a condition where chronic inflammation causes the liver to become irreversibly scarred.

Over time, bands of scar tissue compress the network of blood supply in the liver, leading to increased venous pressure and portal hypertension, which occurs as blood backs up into the portal vein.

Higher portal vein pressure means that fluid in blood vessels gets pushed out of the veins and into the peritoneal cavity, causing ascites.

And she understands that, as pressure in the portal system builds, it can cause splenomegaly, where the spleen becomes enlarged and can trap platelets, leading to thrombocytopenia, easy bruising, and petechiae.

Nurse Abigail also knows that with cirrhosis, the liver’s ability to metabolize bilirubin is impaired, so it builds in the blood, causing jaundice.

Nurse Abigail recognizes that Thomas’ ascites has contributed to his weight gain and can make it difficult to perform physical activities because of increased pressure on his diaphragm, leading to dyspnea.

She also knows that chronic illness in general can cause fatigue. Nurse Abigail realizes Thomas needs management of his fatigue in order to promote mobility.

Now, using the information she's gathered, Nurse Abigail reports her findings to RN Raashida, and together they choose a priority hypothesis of activity intolerance.

Next, they generate solutions to address Thomas’ activity level that will include pharmacologic and nonpharmacologic interventions; and they establish the expected outcome that after intervening, Thomas will tolerate sitting on the edge of the bed for five minutes.

Then, they take action to implement these solutions. RN Raashida calls the health care provider to report the assessment findings and receives orders for an increased dose of Thomas’ prescribed diuretic, furosemide, as well as a repeat physical therapy consult.

Nurse Abigail gathers supplies and re-enters Thomas’ room. Nurse Abigail: Hi Thomas, I have your diuretic medication ordered by your health care provider.

They also ordered physical therapy to come see you again today. How do you feel about that?

Thomas: I don’t know. They’ve come to see me before and it’s frustrating because it’s too hard for me to move around with my belly being so swollen.

Nurse Abigail: I understand that must be uncomfortable. The diuretic medication that I have for you should help with that a little bit.

The physical therapist will also help you with some techniques to make it easier to move around. Thomas: Okay, I guess I’ll give it another try.

Nurse Abigail: Great, I’m glad. Nurse Abigail then administers the furosemide according to the principles of safe medication administration.

As she exits Thomas’ room, she notices the physical therapist has arrived on the unit. After Thomas has finished working with physical therapy, Nurse Abigail reenters the room to evaluate the outcome of her actions.

She takes Thomas’ vital signs, which are temperature 98.8 F or 37 C, heart rate 99 beats per minute, respirations 18 breaths per minute, and blood pressure 105/68 mmHg.

She notes he’s sitting on the edge of the bed reading the dinner menu. Nurse Abigail: Hi, Thomas, how was your session with physical therapy?

Thomas: Good, they taught me some techniques to save up my energy and helped me sit on the edge of the bed, but it’s been about ten minutes now, so I think I’m ready to lie down again.

Nurse Abigail and RN Raashida then assist Thomas back into bed. Alright, as a quick recap… Nurse Abigail recognized and analyzed cues related to Thomas’ activity intolerance and, in collaboration with RN Raashida, prioritized hypotheses and generated solutions to address this problem.

Nurse Abigail and RN Raashida then implemented pharmacologic and nonpharmacologic measures and evaluated Thomas’ outcomes and compared them to the expected outcome.

Since Thomas was able to sit on the edge of the bed for five minutes after working with physical therapy, they determined that the plan of care was met.