CASE PRESENTATION

ON
LIVER CANCER

SUBMITTED TO: SUBMITTED BY:

MRS. MAMATA SWAIN(MAM) RAM NINAD PATTNAIK

ASST. PROFFSOR M.SC NURSING 2nd YEA

SUM NURSING COLLEGE Dept. of gastroenterology

SUBMITTED ON:
 IDENTIFICATION DATA

Client’s name : Mr. Prakash Beg

Age : 58 years
Sex : Male
IP No : 7381755703
Date of admission : 05/01/24
Ward : Gastro ICU
Bed no. :4
Education : uneducated
Occupation : framer
Marital status : Married
Religion : Hinduism
Address : Khorda, odisha
Provisional diagnosis : Liver cancer

I. Presenting Chief Complaints:

The patient complaints for –
1. Fever for 10 days
2. Pain abdomen for 10 days

II. History of Present Illness

The patient was suffering from fever for 10 days of duration and 9 weeks of rigorous and chills of
10 days of duration. Pain abdomen for 10 days diffuse pain mild to moderate in intensity with no history
of radiation pain.
III. Past medical history
a. Hypothyroidism
b. Hypertension
c. Diabetic mellitus
IV. Past surgical History
Mr. Pankaj Beg doesn’t have any past surgical history.
 V. Family History
Mr. Pankaj Beg doesn’t have family history (any kindly of disease condition).

VI. Family characteristics-

Mr. Chandan Behera lives in nuclear family.
S. Name of the Relationship Age Educationa Occupation Health Status Age &
No. family members with the (yr.) / l Status mode of
Patient Sex death

1 Mrs.padama wife 46yr/M Uneducate housewife Not significant -

Beg d

2 Ms. Kamini Daughter 37yrs/F Graduated Housewife/ Healthy -

Pradhan employed

3 Ms. Rachana daughter 32 yrs/F Graduated employed Not significant -

III. Socioeconomic history:

1. My patient is the head of the family.
2. He belongs to a middle class family.
3. He is framer
4. Electricity and water facilities are available in house.
5. Drainage facility is not proper.
6. Income per month: The monthly income is approx. 70,000/-.
7. Expenditure: approx.: 25,000 /- rupees
8. Recreational facilities : Present
9. Medical facilities : Available
IV. Personal History
1. Habits & hobbies: His hobbies are spending time in gardening.
2. Elimination pattern:
▪ Bladder elimination:- cauterization
▪ Bowel elimination:- He passed stool since admission
3. Sleeping pattern: Sleeping pattern is good 8hrs per day
4. Nutritional history :
 Vegetarian / non-vegetarian: Non-vegetarian
Likes / dislikes: He likes all kinds of vegetables & fish.
Any change in the dietary pattern: Avoidance of irritant foods, fried, fast food and balance diet is
advice.
V. Vital Signs:
S.NO Vital Sign Normal Value Patient’s Value

1. Temperature 98.6 F 97.6 F

2. Pulse 60 – 80 Beats/M 82 Beats/M

3. Respiration 14 – 20 Breath/M 22 Breath/M

4. Blood Pressure 120/80 mmHg 150/80 mmHg

VI. Visual Analogue Scale: The pain score of my patient is (4 – 5) and the pain is radiating from left
upper limb to left lower limb.

PHYSICAL EXAMINATION
1. GENERAL APPEARANCE
a. LEVEL OF CONSCIOUSNESS : unconscious and response to all my questions
b. ORIENTATION : gcs was 3
c. SKIN COLOUR : Brown
d. MOOD : Alert
e. ACTIVITY : Active but doctor order to take bed rest
f. BODY BUILD : Obese
g. NOURISHMENT : Well nourished
h. SPEECH : Clear
2. ANTHROPOMETRIC MEASUREMENT
a. WEIGHT : 45 kg
b. HEIGHT : 159 cm
 c. BODY MASS INDEX : 63.4kg/m2
3. HEAD TO FOOT EXAMINATION
I. HEAD
a. SHAPE : Norm cephalic
b. SCALP : Clean
c. HAIR : My patient having black hair and distributed all over the
scalp.
d. FACE : My patient doesn’t have any puffiness or swelling in face.
e. SUBJECTIVE SYMPTOMS : No complaints
II. EYES
a. EYE BROWS : Hair are equally distributed and both eyes brows are
symmetric
b. EYE LASHES : Eye lashes are clean and equally distributed
c. EYE LIDS : Normal
d. PUPILLARY REFLEX: Reacting to light
e. PUPIL SIZE : Round
f. SCLERA : White
g. CONJUNCTIVA : Normal
h. CORNEAL REFLEX : Present
i. VISSION : Normal
j. EYE MOVEMENT : Conjugate eye movement
k. USE OF GLASSES/CONTACT LENSES : My patient is not using any type
of glasses/ contact lens.
l. SUBJECTIVE SYMPTOMS : No complaints
III. EARS
a. USE OF HEARING AIDS : No
b. EAR CANAL : Both the canals are clean
c. TYMPANIC MEMBRANE : Normal
d. HEARING : Weber test is done and my patient can hear in both
the ears
e. SUBJECTIVE SYMPTOMS : No complaint
IV. NOSE
a. EXTERNAL NOSE : Normal in shape and symmetry in size
b. NASAL SEPTUM : Central
c. NASAL POLYPS : Absent
d. NASAL MUCOSA : There is no swelling, bleeding or any
discharge
e. FRONTAL & MAXILLARY SINUSES: Normal
f. SMELL SENTATION : Present
g. SUBJECTIVE SYMPTOMS : No complaint
V. MOUTH & THROAT
 a. LIPS : No redness and swelling and lip is
symmetry
b. TEETH : Clean
c. GUMS : No bleeding is present
d. TONGUE : Clean, moist all around tongue without any
redness
e. UVULA : No tenderness or redness
f. TASTE : Normal taste present
g. BAD ODOUR : Present
h. TONSIL : Enlargement is not present
i. VOICE : Clear
j. SUBJECTIVE SYMPTOMS : No complaint
VI. NECK
a. NECK : No mass is present
b. RANGE OF MOTION : Possible
c. THYROID GLAND : Not enlarged
d. JUGULAR VEIN : Not distended
e. TRACHEA : Midline
f. SUBJECTIVE SYMPTOMS : No complaints
VII. THORAX AND LUNGS
a. THORAX : Symmetrical
b. THORAX EXPAINSION : Normal & Equal
c. BREATH SOUND : 22 breath/min
d. COUGH : Absent
e. SPUTUM : Absent
f. SUBJECTIVE SYMPTOM : No complaints
VIII. HEART
a. HEART SOUND : S1 & S2 sound is present but S3 & S4 is
absent
b. APICAL PULSE : Absent
c. PERIPHERIAL PULSE : 82 beat/min
d. PACEMAKER : Absent
e. OXEYGEN SUPPORT : Absent
f. SUBJECTIVE SYMPTOMS : Room air
IX. GASTROINTESTINAL SYSTEM
a. MOUTH : Clean
b. TEETH : Clean
c. TONGUE : Clean
d. ORAL ULCER : Absent
e. ABDOMEN : Slightly enlarge
f. PERISTALSIS : Present
g. NUTITIONAL ROUTE : Oral feeding
 h. BOWEL OPENED : Present
i. APPETITE : Normal
j. PERCUSSION : Presence of Air
k. INGUINAL LYMPH NODE : No nodes are present
l. LIVER : Normal in size
m. SPLEEN : Normal in size
n. KIDENY : Normal in size
o. BOWEL SOUND : Present
p. PERIANAL SKIN INTEGRITY : Intact
q. SUBJECTIVE SYMPTOMS : No complain
X. GENITOURINARY SYSTEM
a. URINATION : cauterization
b. URINE : No sediments are present
c. GENITALIA : No discharge or edema is present
d. SUBJECTIVE SYMPTOMS : No complain
XI. INTEGUMENTARY SYSTEM
a. SKIN : Intact
b. COLOUR : Brown
c. TEXTURE : Normal
d. TURGOR : Normal
e. HYDRATION : Good
f. TEMPERATURE : 96.3F
g. DISCOLOURATION : Absent
h. CYANOSIS : Absent
i. PERIPHERIES : Warm
j. ICTERUS : Absent
k. LESIONS/MASSES : No lesions/ masses are present
l. SUBJECTIVE SYMPTOMS : No complaint
XII. MUSCULOSKELETAL SYSTEM
a. POSTURAL CURVES : Normal
b. MUSCLE TONE : Normal
c. UPPER EXTRIMITIES
❖ SYMMETRY : Upper extremities are symmetrical
❖ MUSCLE STENGTH : Weakness
❖ RANGE OF MOTION : Possible
❖ BICEPS REFLEX : Normal
❖ TRICEPS REFLEX : Normal
❖ OEDEMA : Absent
❖ JOINTS : NO complaint
❖ DEFORMITY : Absent
d. LOWER EXTERMITIES
❖ SYMMETRY : Lower extremities are symmetrical
 ❖ MUSCLE STRENGTH : Normal
❖ RANGE OF MOTION : Possible
❖ OEDEMA : Absent
❖ JOINTS : No Tenderness
❖ DEFORMITY : Absent
❖ GAIT : Normal
❖ VARICOSE VEINS : Absent
❖ DEPENDENCY LEVEL : Independent
❖ SUBJECTIVE SYMPTOMS : No complaint

LIVER CANCER
DEFINITION:

A liver abscess is defined as a pus-filled mass in the liver that can develop from injury to
the liver or an intra-abdominal infection disseminated from the portal circulation. The
majority of these abscesses are categorized into pyogenic or amoebic, although a
minority is caused by parasites and fungi.

ETIOLOGY-

L.NO ACCORDING TO BOOK ACCORDING TO PATIENT

RISK FACTORS

NON MODIFIEABLE-

Age -above 60 year 58 year

Gender – Female> male male

Genetic

MODIFIEABLE

Diabetes Fasting for long time

High blood pressure No hypertension 140/80

mmHg
Heart and blood vessels

Smoking

Obesity
 Older age

PATHOPHYSIOLOGY

CLINICAL MANIFESTATION

SL.NO ACCORDING TO BOOK ACCORDING TO PATIENT

1. Restlessness Yes

2. Dyspnea Yes

3. Low blood pressure No

4. Confusion No

5. Severe difficulty in breathing Yes

6. Shortness of breathing Yes

7. Tachycardia Yes

8. Cyanosis No

9. Metabolism acidosis Yes

10. Abnormal breath sounds, like crackles Yes

DIAGNOSTIC EVALUATION

1. Physical examination
2. History collection
3. Urine analysis
4. Hematology and biochemistry
5. Serology
6. Upper GI Endoscopy report
7. Ultrasound examination of whole abdomen

SL.N INVESTIGATION PATIENT’S NORMAL INTERPRETATION

O VALUE VALUE

1. Complete blood count

Blood studies

Hemoglobin 9.8 gm/dl 13-17 Decreased

WBC 38.49 4-10 Increased

PLATELET COUNT 278 150- 410 Decreased

TOTAL RBC COUNT 4.99 4.5-5.5 Normal

PCV 29.9% 36.0-52.0 Decreased

59.9fl
MCV 19.6pg 83-101 Decreased

MCH 32.8 g/dl 27-32 Decreased

MCHC 30.9 fl 31.5- 34.5 Normal

RDW-SD 15.2% 39-46 Decreased

RDW-CV 65.0% 11.6-14.0 Increased

MICROCYTIC RBC% 1.0% 0.2-4.5 Normal

MACROCYTIC RBC% 87.8% 3.3-4.8 Decreased

Neutrophil 7.5% 40-80 Increased

Lymphocytes 0.7% 20-40 Decreased

Eosinophil 3.8% 1-6 Decreased

Monocytes 0.2% 2-10 Normal

Basophils 4.1% <1-2% Normal

Immature granulocyte% 0.5% 0.0-0.6 Increased

Nucleated RBC 33.79 0.0-0.0 Increased

NEUTROPHILS# 2.88 2-7 Increased

LYMPHOCYTES 1.48 1.0-3.0 Normal

MONOCYTES# 0.26 0.2-1.0 Increased

EOSINOPHILS# 0.08 0.1-1.1 Decreased

BASOPHILS# 1.58 0.02-0.1 Normal

IMMATURE GRANULOCYTE COUNT# 0.19 0.0-0.06 Increased

NUCLEATED RBC# 15.9 0.0-0.0 Increased

PLATELET DISTRIBUTION WIDTH 10.7 9.0-17.0 Normal

 MEAN PLATELET VOLUME 33.6 8.0-11.0 Normal

PLATELET LARGE CELL RATIO 13.0-43.0 Normal

Routine Investigation
2. 0.11
RBS
0.53mg/dl
Hba1c
1.04mg/dl
S.creatinine
122meq/l
S.sodium
3.81meq/l 135-145
S.potassium
90mEq/L 3.5-5.0
S.Chloride
10.8 96-115
PT control
1.49
INR

ABG
7.409
PH
3. 44.0
PCO2
63.1
PO2
26.9
HCO3

LFT
4. 2.57gm/dl
Bilirubin(T)
2.23gm/dl
BIilirubin(D)
221mg/dl
SGOT
164mg/dl
SGPT
351mg/dl
Alkaline phosphate
4.85mg/dl
Protein
 Albumin 1.99mg/dl

Globulin 2.86gm/dl

BLOOD GROUPING - A positive

Rh typing- Positive

COMPLICATION-

SL NO ACCORDING TO BOOK ACCORDING TO PATIENT

1 Nosocomial pneumonia

2 Barotrauma

3 Renal failure

4 Tracheal ulceration

5 Blood clots

MANAGEMENT

ACCORDING TO BOOK ACCORDING TO PATIENT

1 Non pharmacological measure- 1. Complete bed rest.

2. Eat low sodium and
1. Promote bed rest. protein diet
2. Ensure hydration. 3. Ensure hydration
3. Low sodium and protein diet.
4. Eat high fiber foods.
5. Do not skip food.

Pharmacological management-

1. Antibiotics
2. Anti-inflammatory drugs Inj. Mero
3. Diuretics Inj. Hydrocort
4. Drugs to raise blood pressure
2
 5. Anti-anxiety Inj. Levera
6. Muscles relaxes
7. Bronchodilators Inj. Teicoplanin

Tab. Thyrox

Tab.antiflu

NUTRITIONAL PLAN-
Calories- 1600kcl /day

Protein- 1gm /kg/bodyweight

Fibers-30-35gms

Carbohydrate-160gm

Fluids- 1.5lit/day

PROGRESS NOTE

SL.N DATE NURSE’S NOTES

O

1. 10.01.2024 Patient was conscious and Pain. The patient had semi fowler position and
medication as ordered.

Bp- 120/80mmhg

Pulse 82/min

RR-26/min

Temp-98.4F

Spo2-100% in room air

Patient maintained urination and BP.

Advice Ultrasound and Endoscopy

Today patient is unconscious .generalised weakness.

2. 11.01.2024
 BP-130/80mmhg

PR-80/min

Temp-98.4F

SPO2-98%

Advice for CBC,LFT,RFT,T3,T4 and TSH

Administrate IV Fluid.

3. 12.01.2024 The patient is unconscious. Her vitals are stable.

Na+= 128meq/l

K+= 3.9meq/l

CL-44meq/l

HGT-134mg/dl

ABG Value

PH-7.38

PCO2-40mmhg

Po2-89mmhg

Hco3-23.01mmol/L

Na+ -142meq/L

K+ -3.4meq/L

Cl -48meq/l

HGT-124mg/dl

APPLICATON OF VERGINIA HENDERSON’S NEED THEORY IN NURSING PROCESS-

Henderson was born on 30th November, 1897 in Kansas City, Missouri and dies on 17th march 1996.

She called as “the Nightingale of modern nursing”, “Modern -day mother of nursing”

She earned her Diploma in nursing .from the army school of nursing in 1921, Bsc .in 1932, M.A in 1934.

She worked as a teaching nursing in 1923, member of faculty. And research associate.
She was honored at the annual meeting of the nursing and allied health section on the medical library
association.

She created basic nursing curriculum for nursing in 1937

She developed the theory in 1950 -1970.

She proposed 14 components of basic nursing care.

1. Pain reduce
2. Eat and drink adequately.
3. Eliminate body waste
4. Move and maintain desirable posture
5. sleep and maintain desirable posture
6. sleep and rest
7. select suitable clothes-dress and undress
8. Maintain body temperature within normal range
9. Keep body clean and well groomed and protect from injury.
10.Avoid dangers in the environment and avoid injuries others
11.Communicating with others in expressing feeling
12.worship according to one’s faith
13.work in such a way that there is a sense of accomplishment
14.Play and participate in various forms of recreation, learn, discover, or satisfy the curiosity that
leads to normal development.
Nursing care plan :( By q application of nursing theory)

ASSESSMENT

Patient had abdomen pain , assess the location, severity(0-10 scale) and character of pain.

⮚ Eat inadequate diet ,she was thirsty demanded more orally fluids
⮚ Elimination Patient was self-void ,no bowel movement, since two days
⮚ Moving: Able to move self in bed without support.
⮚ Dressing and undressing appropriately: she was dressed independently.
⮚ Avoiding dangers and injury to others: she was conscious and orientated and able to follow the
instruction regarding safety.
⮚ Communication: she was able to express self clearly. Hear and saw clearly.

NURSING DIAGNOSIS:-

1. Acute pain related to chest pain as evidenced by patient’s verbalization and facial expression.
2. Imbalanced Nutrition less than body requirements related to Loss of appetite as
evidenced by weakness.
3. Ineffective breathing pattern related to decreased lung compliance
4. Impaired gas exchange related to diffusion defect as defect as characterized by hypoxia.
 5. Risk for decreased cardiac output related to positive pressure ventilation.
ASSESSMEN NURSING GOAL PLANNING IMPLEMENTATION RATIONALE EVALUATION
T
DIAGNOSIS

Subjective Acute pain Patient Assess the -monitored location, To identify Patient pain
data: related to will be cause ,locati duration, intensity of type and was relieved.
chest pain as relief on and pain, by using 0 to severity of She feels
Patient says evidenced by abdominal severity of 10 scale in pain pain. comfort.
that feel pain patient pain and pain scale.
in abdomen, verbalization decreased
indigestion, and facial in pain
aggravated expression. scale.
pain after a -Monitored blood
heavy meal pressure, pulse and
from 6-7 days respiration. -To obtain
Monitor baseline data.
vital signs
-Provide comfortable
position by lying on
Objective data: left lateral position.
Provide
comfortable - To feel
Tenderness
position comfort.
and rigid
abdomen right -Administered
upper quadrant Analgesic as per
and facial doctor’s advice-
expression Diclofenac.
VAS-4

Administere
d Analgesic
To relieve
pain
Subjective Imbalanced Patient Assess the Checked nutritional To collect
data: nutrition less nutritional nutritional status the baseline
than body status will status and data Patient’s
Patient says requirement be needs of the nutritional
that feel related to improved patient status was
weakness, loss of improved as
indigestion appetite as evidenced by
and nausea evidenced by increase
Assess the To identify
weakness weight
Objective weight and BMI
data: BMI Checked weight-45
KG
Abdominal Advice for To prevent
pain score healthy diet BMI-63.4kg/m2 indigestion
increased,
Weight
decreased
Advice for healthy
BMI-
diet like high-fiber
underweight
food and avoid fat
diet

Encourage Rest for 6-7 hours

patient for
bed rest To easily
Administered IV digestion
fluid like NS,DNS
and RL as per
doctor’s order
Administere
d IV fluid

As per To improve
doctor’s hydration
order

Subjective Ineffective Patient Assess Assessed the To know the Patient was
data: breathing will be breathing breathing pattern pattern improved the
pattern reduced pattern breathing
Patient says lung pattern
that she is related to
complianc
having decreased
e
difficulty in lung
To collect
breathing compliance
Monitor the baseline
Monitor vital sign-
 vital sign BP, pulse and data
respiration
Objective
data ;
Monitor To know
By breathing Maintain chart status
observation pattern hourly

Administer Administered
ventilator as ventilator as per To maintain
per doctor’s doctor advice
advice

Subjective Impaired Patient Asses the Assessed behavioral To know the Patient
data: gas will be patient response. baseline data
reduced hypoxia Anxiety was
exchange
hypoxia reduced some
related to extent.
diffusion to take 6-7 hours To reduce
defect as to take rest
Objective
defect as
data:
characterize nebulizer to use
By d by Provide
observation directional To feel relax
hypoxia
therapy

Subjective Risk for Patient Assess the Assess the patient the patient Patient
data: decreased will be patient know cardiac output cardiac management
cardiac having cardiac output of cardiac
output cardiac output output
output
related to
positive
Objective Check Vital Inj. Nora
pressure
data : sign
ventilation.
By
observation Educate the disease
Advice condition its causes, To gain
sign and symptoms, knowledge
 Educate the complication and regarding the
disease treatment disease
condition condition

HEALTH EDUCATION-

DIET-

- Advice does not skip meals.

- Instruct for take 800ml water per day.
- Advice to eat low protein and sodium diet.
- Avoid high spicy and fatty food.
- Teach maintain about input and output chart.
- Vital signs and weight regularly.

Management of disease condition

- Teach the patient and family members about cause ,effects,treatment,prognosis and complication.
- Teach the patient to recognize and report complication.
- Advice the family members for provide home care to the patient.
- Teach relaxation techniques i.e like watching TV ,reading news paper,meditation.
- Do regular exercise to maintain healthy weight.

Medication

- Teach the patient and family member about time and frequency of taking medication.
- Teach the family members for skip of drug may induce serious complication.
- Teach about side effects of medication.
- Advice to complete the course of medication.

Follow up-

- Instruct the patient to review for re-checkup as a prescribed.

- Advise that if any side effects occur then report to the physician.
- Advice for regular RFT.

CONCLUSION

The increased burden of ARDS in developing countries is due to globalization low soico economic status
and poor access to health care and health care disparities.

BIBLIOGRAPHY
Brunner & Suddharth’s. Textbook of Medical Surgical Nursing; 11th edi; New Delhi: Reed elseiver .- (p)
LTD Page no-