Nursing Interventions for Pain and Depression in a Patient with Alcoholic Liver Disease

The essay explores the etiology and symptoms of pain and depression in a patient with alcoholic liver disease. The nursing interventions for pain and depression include pharmacological and non-pharmacological interventions.

Pain and Depression 1
NURSING INTERVENTIONS: PAIN AND DEPRESSION
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Pain and Depression 2
Introduction
The case scenario talks about Ravi Maharaj, a 59-year-old patient diagnosed with
alcoholic liver disease. The complication has impaired the functions of the liver beyond
treatment. However, the liver consultant has advised the family of Mr. Ravi to assist him in
managing the symptoms. The district nurses and the palliative care team will help the family to
care for the patient. The patient feels a generalized pain especially in the left abdomen due to the
liver disease. Additionally, he is jaundice in appearance and experiences depression and stress.
The district nurse observes that Mr. Ravi has a tearful mood indicating that he has developed a
major depressive disorder. This paper will use the Roper, Logan, Tierney model to assess the
condition of the patient, the model discuses the activities of life (ALs) which include sleeping,
eating, movement, communication, breathing among others. Alcoholic liver disease limits the
ability of Ravi to perform the ALs. Additionally, the pain limits him from having adequate sleep
at night. Ravi cannot perform all the activities of life due to his condition. The assessment model
forms part of the care plan in the appendix section. The essay will explore the etiology and
symptoms of the two clinical issues. It will explore clinical interventions for two nursing
problems including pain and depression. It will also discuss the objective and subjective data on
the general pain affecting the patient. Pain and depression stand out as the two significant
symptoms that require active management in palliative care. Therefore, the caregivers must
prioritize care for them.
The Roper, Logan, and Tierney model
The model explores the activities of life (AL) and the ability of an individual to conduct
them (Williams, 2017). Individuals who can perform the actions lead a comfortable life full of
satisfaction and independence. However, ailments limit the ability of a person to live an
independent life. Therefore, essential clinical interventions are necessary to restore the

Pain and Depression 3
independence of an individual. Examples of activities of life include sleeping, mobilization,
working, and eating. According to the case scenario, Ravi becomes exhausted after small tasks
insinuating that the complication interferes with his ability to work. The drainage of ascites
prevents the patient from sleeping forcing him to sleep on the chair. The patient cannot have a
proper meal as he is tolerating a small portion of food. The client also finds difficulty in
movement without the use of a walking stick. The care plan in the appendix section uses the
model to suggest proper interventions for the patient.
Pathophysiology of Alcoholic Liver Disease (ALD)
ALD is a broad term for liver complications due to excessive alcohol consumption
(Petrasek et al., 2015). Alcoholic liver complications include alcoholic hepatitis, fatty liver,
cirrhosis, and chronic hepatitis. During alcohol consumption, a majority of the drink undergoes
detoxification in the liver. Excessive alcohol intake leads to pro-inflammatory cytokines
secretion. The cytokine factors cause liver complications like inflammation and apoptosis of the
cells.
Clinical Problems
Pain
Etiology
According to the case study, Ravi experiences general pain mainly in the left upper
abdomen due to liver disease. Therefore, it is right to conclude that the patient has abdominal
pains.
Subjective and Objective Data
The subjective data include decreased appetite and nausea. According to the case
scenario, Ravi is tolerating small portions of food. At times, he remains nauseous throughout the

Pain and Depression 4
data. Other subjective data include muscle tension and rebound tenderness (Jangland, Kitson,
and Muntlin Athlin, 2016). Abdominal pain also causes the patient to be restless. The objective
data include diarrhea, constipation, and vomiting. Since Ravi is nauseous, he can vomit easily.
The patient also experiences a recurrent accumulation of fluids in his abdomen.
In the case study, Ravi experiences general pain in the upper abdominal section.
Laboratory tests and physical examination always follow the cross-examination between the
patient and the caregiver. The laboratory tests seek to examine the pancreatic and liver enzymes.
Other diagnostic tools include abdominal x-rays and radiographic studies (Sidhu et al., 2015).
Ultrasound, MRI, and capsule endoscopy are also useful in assessing abdominal pain. Additional
diagnosis can rely on endoscopic ultrasound, colonoscopy, and CT.
Symptoms
The symptoms include dehydration, fever and bloating (Viniol et al., 2014). The patient
cannot store food in the system for more than three days. Dehydration signs and the inability to
urinate or pass stool are also associated with the pain. According to the case study, Ravi passes
small amounts of urine. The patient experiences pain when passing urine. The pain always
persists for many hours during the day and night. Belching, bloating and ingestion are the other
symptoms of pain in the left upper abdomen. Heartburn, GERD, and diarrhea are also associated
with abdominal pain. Therefore, appropriate pharmacological and non-pharmacological
interventions are necessary to manage the pain.
Nursing Interventions
Pharmacological Intervention
Pain relievers issued over the counter can help in reducing the severity of the pain
(Camilleri, and Boeckxstaens, 2017). The physician can also prescribe medications of general
pain to patients experiencing abdominal discomfort. Antibiotics are also efficient remedies for

Pain and Depression 5
any forms of pain. Recent studies have indicated that depression can increase the severity of
illness (Camilleri, and Boeckxstaens, 2017). Therefore, a low dose of antidepressants is
necessary for easing the pain. According to the case scenario, Ravi's pain emanates from liver
disease. Thus, the family, district nurse, and the palliative care unit should ensure that the patient
takes the liver disease medications.
Non-Pharmacological Interventions
The first intervention for easing the pain is massage. A significant number of patients
derive pain relief from massage (Smith et al., 2018). The palliative care unit should request
trained massage therapists to assist Ravi in managing the pain. Massage is an effective pain
reliever according to recent studies. Apart from pain, massage can eliminate symptoms of other
severe ailments. Relaxation techniques are also viable alternatives for pain medications (Mann,
and Carr, 2018). The methods include biofeedback and hypnosis. Guided imagery and breathing
techniques also help relax the muscles of the patient. Tai Chi, which is a gentle movement, has
also proven to be an alternative to pain medications. According to Mann and Carr (2018),
relaxation techniques not only relieve pain but also eliminate stress and anxiety in both the
caregiver and Ravi. Therefore, the methods can solve Ravi's stressful condition.
Pet therapy works best for individuals experiencing pain that lasts for few minutes. Such
an individual should look for a fun item like a soft spur of an animal. Pet therapy involves
animal-assisted remedy and pet-assisted activities (Barker et al., 2015). Animal-assisted therapy
relies on dogs and other pet animals like cats to assist individuals to recover from pain. The pet
acts as a source of entertainment to the patient. Therefore, being happy eliminates the thoughts of
pain.
Gel packs also help in relieving several types of pains as the abdominal constraints
(Stivers et al., 2018). The health specialists can either chill or warm the packs. Afterward, the

Pain and Depression 6
health specialist uses the appropriate pack for pain management. According to Stivers et al.,
(2018), Cold therapy reduces inflammation and swelling. On the other hand, heat therapy
relieves pain such as localized arthritis stains. The gel packs serve as alternatives to traditional
heating pads and hot water bottles. An elastic-gel wrap can provide cold or heat therapy to the
body. Cryotherapy also helps in eliminating pain. The therapy is achievable by using ice packs or
ice attached to dispensers of cold water. Cryotherapy can reduce inter-muscular temperature by
7ºC (Steer, and Chand, 2018). A reduction of temperature decreases pain, inflammation, and
local metabolism. The therapy reduces the velocity of nerve conduction along the fibers of pain.
Depression and Anxiety
Etiology
Circumstances surrounding Ravi's liver disease has made him develop a depressive
disorder. The district nurse observes that the patient is tearful, which is a symptom of stress. Ravi
is worried about the stress his wife will undergo due to his choice of dying at home. A depressive
disorder is a psychiatric condition that makes a patient harbor a consistent sadness feeling.
Clinical depression prevents individuals from conducting daily chores (Schmaal et al., 2016).
Physical exam and laboratory tests are useful in gauging whether an individual has a major
depressive disorder or otherwise. Psychiatric evaluation and DSM-5 tool are also crucial in
diagnosis (Muris et al., 2017). Physical exams involve the caregiver cross-examining the patient
about health status. In certain circumstances, depression occurs due to problems with physical
health. For example, Ravi's alcoholic liver disease is the primary cause of depression. Lab tests
can gauge the functioning of the thyroid. During the psychiatric evaluation, the specialist can ask
the patient about behavior patterns, feelings, thoughts, and symptoms of the condition. DSM-5 is
a criterion that tests the five significant symptoms of depression. A patient that exhibits the five
signs has clinical depression.

Pain and Depression 7
Symptoms
Depression and anxiety make the patients feel sad, hopeless, empty, and tearful
(Garnefski, and Kraaij, 2018). In the case scenario, the district nurse visits Ravi and finds him in
a tearful mood implying that he is depressed. The mental condition makes an individual to lose
interest in usual activities like sports. Excessive sleep, insomnia, and sleep disturbances are also
associated with depression. A depressed individual is always tired and even loses appetite.
According to the case scenario, Ravi becomes exhausted after small tasks and spends most of his
time sleeping. Depression also makes an individual feel guilty and worthless. In the case study,
Ravi is feeling guilty that his alcohol intake led to his terminal condition.
Nursing Interventions
Pharmacological Interventions
The psychiatrists can prescribe various drugs like antidepressants to reduce the severity
of depressive symptoms (Keszthelyi, and Masclee, 2016). Tricyclic antidepressants are effective
in managing depression. However, the numerous side effects associated with this class of
antidepressants makes the less preferable in controlling depression. Tricyclic antidepressants
include imipramine, desipramine, and doxepin (Keszthelyi, and Masclee, 2016). Atypical
antidepressants are also useful in treating clinical depression. The antidepressants include
trazodone, nefazodone, vortioxetine, and bupropion (Parkin et al., 2017). Inhibitors of serotine
reuptake (SSRIs) are also useful in primary depressive disorder management. SSRIs have few
side effects than the antidepressants hence considered to be safe medications (Parkin et al.,
2017). The SSRIs include paroxetine, fluoxetine, escitalopram, and citalopram (McCrea et al.,
2016). Inhibitors of serotonin-norepinephrine reuptake (SNRIs) are also useful in managing
depression. SNRIs include desvenlafaxine, venlafaxine, levomilnacipran, and duloxetine.
Psychiatrists can prescribe Inhibitors of monoamine oxidase (MAOIs) if the other drugs fail to

Pain and Depression 8
manage depression. The MAOIs include phenelzine, isocarboxazid, and tranylcypromine
(O’Leary et al., 2015). The doctor can also recommend the combination of two antidepressants
to manage the clinical depression symptoms. Antipsychotics or mood stabilizers are also
efficient remedies for depression. Stimulant medications and anti-anxiety are also useful in
reducing the levels of anxiety.
Non-Pharmacological Interventions
Psychotherapy is a viable alternative for the antidepressant medications as it eliminates
the chances of the side effects. Psychotherapy or talk therapy involves the conversation between
the psychiatrist and the patient about depression and other issues related to the mental
complication (Barth et al., 2016). Examples of psychotherapies that are effective for clinical
depression patients include interpersonal, behavioral, and cognitive therapy. Psychotherapy helps
the victim to tolerate the prevailing health conditions (Barth et al., 2016). Talk therapy also
recognizes negative behaviors and beliefs before replacing them with positive and healthy
thoughts. The treatment also suggests practical ways of solving problems. Therefore,
psychotherapy enables the depression patient to accept the prevailing situations.
Home remedies and lifestyle changes can also assist in reducing the severity of
depressions symptoms. The district nurse and the palliative care unit should help Ravi stick to his
treatment plan. The patient should take the medications per the doctor’s prescription. The
palliative care unit should also train the patient on depression and the appropriate ways of coping
with the mental complication. The client should also avoid recreational drugs and alcohol as the
two worsen the symptoms of the disease. The patient should take care of himself by eating a
healthy diet and conducting a physical exercise. The client should also get adequate rest at night.
Conclusion

Pain and Depression 9
Mr. Ravi developed alcoholic liver disease due to his excessive alcohol intake. His
condition has made him experience general pain and depression. Roper, Logan, and Tierney
model are useful in assessing the nature of Ravi's conditions. The model explores the activities of
life that a healthy individual can perform. The activities include eating, sleeping, moving around,
among others. An individual who can perform all the activities independently is considered
healthy. However, the inability to perform an activity of life can be due to an infection. Ravi's
state has interfered with his ability to perform various chores. The liver diseases have limited the
ability of the patient to eat, sleep, and move from one place to the other. Ravi also gets exhausted
after conducting a few duties and tends to sleep most of the time. The patient experiences general
pain due to liver disease. The strain is dominant on the upper section of the abdomen. Laboratory
tests and physical examination are useful in diagnosing abdominal pain. Symptoms of abdominal
pain include nausea, vomiting, diarrhea, and bloating. The symptoms require urgent attention to
ensure that Ravi resumes his daily activities. Both pharmacological and non-pharmacological
remedies can manage the pain. Drugs like antibiotics and painkillers help to relieve pain from an
individual. However, some antibiotics can have side effects. Therefore, patients should opt for
other remedies. Non-pharmacological remedies include pet therapy, cryotherapy, and relaxation
therapy among others. The therapies help the patient to relax and also reduce the intensity of
pain. Ravi also developed depression due to his physical status of health. The patient is worried
about how his wife will cope once he is gone. The diagnosis is through physical examination and
laboratory tests. The intensity of a physical complication can increase the severity of major
depressive disorder. The symptoms of clinical depression include hopelessness, insomnia, and
sadness. The pharmacological remedy involves the intake of antidepressants and other drugs.
Antidepressants like cyclic varieties have several side effects. Non-pharmacological therapies

Pain and Depression 10
include psychotherapy, home, and lifestyle remedies. The remedies are effective alternatives of
pharmacological remedies since they lack undesirable effects like nausea among others.

Pain and Depression 11
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Pain and Depression 12
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Pain and Depression 13
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Pain and Depression 15
Appendix
Care Plan
Patient’s Name: Ravi Maharaj
Date of Birth: 1st May 1959
Assessment Nursing
Diagnosis
Problem (PES)
GOAL
(SMART)
Nursing Intervention
Roper, Logan, and
Tierney Model
Activities of Living
(AL)
Sleeping: Ravi
cannot sleep well,
and he is very tired.
Eating: the patient is
tolerating small
portions of food
Mobilisation: the
patient, is unable to
attend the temple
Breathing: the
terminal liver disease
prevents the patient
from having proper
breath.
Pain
Etiology: general
pain is caused by
liver disease and
its affects the left
part of the
abdomen
Symptoms:
vomiting,
diarrhea, and
bloating among
others
To eliminate
the patient’s
pain within
two weeks
Pharmacological Interventions
 Prescribing painkillers for
the pain like Biaxin
(Camilleri, and
Boeckxstaens, 2017)
 Prescribing liver disease
medications like tylenol
 Other relevant abdominal
pain medications like
Cipro
 Administering antibiotics
like Levaquin
Non-pharmacological
Interventions
 Massage (Smith et al.,
2018)
 Pet therapy (Barker et al.,
2015)
 Using gel packs
 Cryotherapy
Sleeping: the patient
spends most of his
time sleeping
(oversleeping)
Working: Ravi
becomes exhausted
after small tasks
The terminal
condition prevents
Ravi from
conducting the
following activities
of life
Maintaining a safe
Depression and
Anxiety
Etiology: The
terminal liver
disease is a
source of
depression for
the patient
He is also tearful
due to the
thoughts of
leaving the wife
alone after his
death
To lower the
severity of the
depression
symptoms
within one
week
Pharmacological Interventions
Prescribing and administering:
 Tricyclic antidepressants
(Keszthelyi, and Masclee,
2016)
 Atypical antidepressants
 SSRIs (McCrea et al.,
2016)
 SNRIs
 MAOIs (O’Leary et al.,
2015)
Non-pharmacological
Interventions
 Psychotherapy

Pain and Depression 16
environment
Communication
Eating and Drinking
Washing and
Dressing
Expressing Sexuality
Death and Dying
Symptoms:
sadness, feeling
guilty, and
insomnia among
others
 Electroconvulsive therapy
 Home Remedies
 Lifestyle remedies
 Palliative Care
Evaluation: Taking the prescribed painkillers and antibiotics will lower the general pain.
Additionally, the non-pharmacological intervention also eliminates the abdominal pain. The
patient can use SSRIs, SNRIs, and MAOIs over the antidepressants due to a reduced number of
side effects. However, psychotherapy also reduces the symptoms of major depressive disorder.