Comprehensive Assessment and Care Plan for Nursing Patients with Alcoholic Liver Disease

This essay provides a comprehensive assessment and care plan for nursing patients with alcoholic liver disease, focusing on interventions and evidence-based practice.

Running head: NURSING
Topic: NURSING
Name of the Student:
Name of the University:
Author’s Note:

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Introduction
The main aim of the essay is to perform a comprehensive assessment related to nursing and
critical analysis of the interventions which are used for the implementation of the patients’ needs
under proper surveillance of community based palliative care team. A nursing care plan has been
drafted in reference to the nursing process to highlight two nursing priorities for patient’s care. The
essay will also highlight the critical appraisal of the assessment framework along with a detailed
description of the pathophysiology of the patient’s condition and importance of other nursing
assessment tools. In addition to this, proper pharmacological and non-pharmacological
interventions will be studied and rationalized in relation to the relevant guidelines. Finally the
effectiveness of the interventions implemented will be examined in-line with the evidence-based
practice. The critical analysis of this selected scenario with focus on Mr. Ravi who is 59yrs old,
recently diagnosed (6-month ago) with end stage Alcoholic Liver Disease. Ravi used to be a heavy
drinker consuming 50 units per week but over the last 8-month he has quit consumption of alcohol.
He was admitted to the hospital for proper monitoring of his liver function and drainage of ascetics.
He has a past medical history of type 2 diabetes mellitus and hypertension.
According to Berman et al. (2010), determination of the health status of the person is an
important part of holistic care approach. An integral part of the patient care is provision of vital
information, which helps the nurses to proceed with an effective and evidence-based care. There are
numerous frameworks for health assessments of Mr. Ravi depending on the severity of the
patient’s illness and settings. In relation to this, it can be said that ABCDE approach is not suitable
as highlighted by the Resuscitation Council of UK (2015). According to the Resuscitation Council
of UK (2015), ABCDE approach involves a systematic way of assessing, identifying and treating
life-threatening problems under clinical emergencies .It is not fruitful in assessing terminal health
condition like that of Mr Ravi. Thus, Roper Logan Tierney framework for the activities of daily
living (2000 model) is preferred over the other models for the assessment of the current health

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conditions of Mr Ravi. This framework will assess the activates involved in the case study. As Mr.
Ravi has clearly stated that he did not want to be admitted to an ICU or to die in hospital, a person-
centred care plan will be effective for Ravi in order to manage his symptoms in this terminal stage
of the disease. In this essay, APIE (Assessment, Planning, Intervention and Evaluation) approach
will also be used for critically analysis of Ravi’s need and framing of the care plan.
The nursing problems, which has been prioritized for Mr. Ravi are ascites (distended
abdomen due to fluid retention) and generalized pain (mainly in the left-upper abdomen use to liver
disease). The distended abdomen before drainage of ascites water was making Mr. Ravi
incompetent to lay down as sleep and thus he was sleeping over a chair. The case study revealed
that Mr. Ravi, during the course of his admission had repeated drainage of ascitic fluid drainage due
to the recurrent accumulation in abdomen. Thus it is considered as nursing priority. According to
Ballesteros, Centeno and Arantzamendi (2014) the main principle for the end of life care or
palliative care is to manage the symptoms and reduce the suffering of the individuals, and thus
management of generalised pain was selected as second nursing priority.
Discussion:
According to the case, study, Mr. Ravi is suffering from the end-stage alcoholic liver
disease, diagnosed 6-month ago. The severity of liver diseases has been prevalent throughout the
world, especially in UK. As per the reports from the government of UK, the rate of alcoholic liver
diseases is significantly higher in males (11.9 per 100,000 people under 75) than in females (6.1 per
100,000 people under 75). Moreover, there have been almost 26265 premature deaths related to
liver diseases in England and 18.5 deaths per 100,000 people who are over 75 years of age
(Government of UK 2019). As far as the case of Mr. Ravi Maharaj is concern, he was suffering
from alcoholic liver disease and is at the terminal stage of the disease. Pathophysiology of alcoholic
liver disease (ALD) is associated with spectrum of disorder starting from asymptomatic steatosis,

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fibrosis, alcoholic steatohepatitis, cirrhosis, fibrosis and its associated complications. The main
symptom identified is distended abdomen due to ascites.
According to Biecker (2011) ascites is a major complication of ALD and is linked
with poor prognosis. At least 50% of the patients develop ascites within 10 years of diagnosis. Thus
Mr. Ravi might have been suffering from ALD for more than a year, highlighting lack of early
disease detection. Biecker (2011) is of the opinion that Ascites is a combination of elevated portal
hypertension (pressure in the veins running through the liver) and a decreased liver function which
is caused by scarring of liver (cirrhosis). Mr. Ravi has a past history of hypertension and his ascites
might be due to his liver cirrhosis along with elevated blood pressure. Jüngst et al. (2013), further
highlighted that ALD is associated with the damage in the liver resulting from alcohol-related
scarring. The damage of the liver is manifested as swelling and inflammation of the hepatic cells,
causing pain in left upper side of the abdomen. ALD cause decrease in the function of the liver as a
result, the hepatic cells loose it capacity to drain toxic protein and amino-acid by-products from the
body resulting in accumulation within the body. Bilirubin is one of the harmful by-products of
metabolism which is excreted by the liver. During ALD, liver is unable to execute tis function
properly leading to the deposition of the bilirubin beneath the skin, giving jaundice like appearance
(Jüngst et al. 2013).
As far as etiology is concerned, most common reason behind the development of the ALD
in case of Mr. Ravi is his addiction towards alcohol. As per the case study, Mr. Ravi used to drink
reason 50 units of alcohol per week until 8-months ago from the present scenario and was on
General Practitioner’s (GP) guidance to reduce the alcohol intake (Biecker 2011). Another etiology
behind the disease development is Mr. Ravi’s past medical history of type-2 Diabetes Mellitus
(T2DM). T2DM is associated with hyperglycaemia and compensatory hyperinsulinaemia. High
level of glucose in the blood (hyperglycemia) results in hyperglycaemia-induced oxidative stress,
leading to injury of liver tissue (Mohamed et al. 2016).

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Critical appraisal of the assessment framework and its impact on the plan of care
The Roper Logan Tierney Framework has been considered in the following case study
consisting of Mr Ravi and his serious condition of liver disease. The chosen model gives focus on
the models of living and aims to facilitate the various methods of teaching along with learning the
various requirements of the patient through an effective assessment and implementation of a useful
method of care planning for the patient (Williams,2015). Nelson and Carey (2016) further supports
the fact that the RLT model provides the basic framework for the caring and assessment of care
planning and mainly for people who have particular disabilities alongside complex as well as
multiple need pertaining to health activities. It mainly explores the 12 main activities utilised in a
basic living.

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Figure: 12 factors of Roper Logan Tierney Framework for Activities for Daily Living
(Source: nccih.nih.gov, 2019).
According to the scenario, the main activities related to Mr. Ravi includes Dying, Mobility
under safe environment and Eating and drinking. The main assessment parameters for Dying
include cultural and religious beliefs, family and friends and next to kin. Mr. Ravi’s cultural and
spiritual beliefs are taking a toll on his mental health. As per the case study, Ravi being a Hindu is
unable to visit temple regularly due to physical weakness post hospital discharge. He feels that

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without spiritual support he is struggling to come to terms with his diagnosis. Ravi is also feeling
guilty as his terminal condition was brought about by excessive alcohol intake which is strictly
forbidden within his culture. In the domain of mobility, it can be said that Ravi though able to move
from bed to a chair but at times finds needs support like walking stick. The eating and drinking
habits of Mr. Ravi is another important concern behind the activities of daily living as he is required
to restrict the intake of alcohol, and needs to be on proper diet in order to manage his type 2
Diabetes and ALD. Moreover, Mr.Ravi is tolerating small portions of food, he is underweight and
remains nauseous at times throughout the day thus proper diet planning is important for Mr. Ravi.
The above framework has been beneficial for decision making in case of Mr Ravi. In the
following case, Mr Ravi has chosen a family care approach to be provided where care and support
will be supplied to him at home. According to Care (2018), family centred care is the best possible
method as it considers patients as an integral part of the healthcare system and put the care and
support of the patient above all medical interventions. Such a plan would help to suffice the daily
living activity of Dying. In order to control the need for eating and drinking, proper diet plan for
Ravi is important and this would include small meals (mostly liquid or semi-liquid) given in small
interval in order to increase his BMI, nutritional level. Biecker (2011) also recommends a salt
restricted diet for the effective management of ascites. The diet plan should also be devoid of sugar
in order to manage T2DM (Zhou, Zhang and Qiao 2014). In order to manage proper mobilization,
Mr. Ravi must be assisted with manual support along with technological assistance like recliner
chair, bed, wheel chair and walker. The floor must be slippage resistance with the use of shoes with
traction soles and proper indoor lightening. This will help in the prevention of accidental fall
(Ambrose, Paul and Hausdorff 2013).
Analysis of assessment tools used and impact of subjective and objective data on decision
making process

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The use of various procedures like the Waterlow scores have been useful in assessing the
requirements of the patients. Waterlow scores are aimed for prediction of the outcomes of the
survey which are used in pre-operative counselling for guide management involving facilitation of
internal or external audit. It is included in UK hospitals for stratification of the risk of various
diseases. The water low score has been significantly lower than the usual scores depicted by the
original studies conducted in some hospitals in UK (Mahalingham et al. 2014). Mr Ravi has shown
skin problems including presence of scaly and itchy skin which can be assessed though the
Waterlow assessment tool under the skin type assessment category. The National Early Warning
Scores has also been used in the assessment of the case study pertaining to Mr Ravi. The
physiological parameter which has been used in the case study involve the saturation of the oxygen
levels. Moreover, the blood pressure of the patient along with pulse rate, levels of consciousness
and the normal temperature of the patients have been considered as assessment factors for
providing proper plan of care to the patient Mr Ravi in this case (rcplondon.ac.uk, 2019). The
combination of subjective as well as objective assessment is useful in understanding the exact
requirements of the patients. Hydes et al.(2016) have observed that the NEWS score will be
beneficial for the cases of Mr Ravi as it will compare the present scenario on the basis of death risks
and will help them in the admission to ICU or intensive care units. Moreover, it is an easily
available readymade method for the identification of patients especially with liver disease who must
require intervention without modification of internal and external parameters (Hydes et al.,2018).
According to the claims of (Appleboom et al.2014), patient reported outcomes have been used
which help in qualifying and tele-monitoring of self-hybrid models which helps in encouraging the
active participation of the patients by giving a descriptive analysis of the subjective data given to
the provider. According to subjective data analysis, Mr Ravi have not been able to sleep well for
many days and been suffering from unnecessary fatigue and has not been able to attend religious
ceremonies including visiting temples. Moreover, he also been guilty of the fact that his health has

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declined due to the increase in alcohol levels. Objective assessments including the case of Mr Ravi
have found that surgical procedures are necessary apart from symptom based treatment. According
to the medical reports, the condition of his liver has declined. He has also shown symptoms of
increased ascetic fluid drainage and subsequently jaundiced appearance. According to Beck
Tornquist and Edberg (2014), the implementation of palliative care have helped to focus of the
aspects of relationship and a proper idea regarding the patients interaction with the relatives and
family members and thus is a better idea for its incorporation in the plan of care.
Identification of nursing problems and its impact on the decision making process for the plan
of care
Fluid retention and generalized pain are the main nursing problems requiring proper
monitoring and intensive care plan.
Assessment of the ascites will be done through ascitic fluid analysis. This will include
estimation of the total protein concentration, analysis of the neutrophil count and inoculation of
ascites into blood culture bottles. Proper examination of fluid retention in stomach is important
because continuous fluid retention might lead to kidney or heart failure. The main nursing
intervention for the management of ascites or retention of fluid in the abdomen includes restriction
of sodium in the diet plan along with diuretic therapy. Sodium intake should be restricted at the
range of 5-6 g/d (83-100 mmol/d NaCl) (Biecker 2011). A stringent restriction is not recommended
as this kind of diet is distasteful and might worsen rate of food intake increasing the chances of
malnutrition. According to Sampson and his research team (2014), the theoretical concept behind
the underlying interventions is important apart from the clinical methodologies. The theoretical
concept behind the underlying non-pharmacological intervention for the effective management of
the fluid retention is limited intake of salt or sodium helps to keep the positive balance between the
sodium and potassium and thereby helping to faster mobilization of the fluid through urine (Biecker
2011). Another non-pharmacological intervention for ascites include restricted intake of fluid. Since

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the urine output is low for Mr. Ravi, restricted fluid intake will be helpful in managing the fluid
retention in stomach (Shaw et al. 2013). The evaluation will be done based on examining the size of
the stomach.
For the introduction of the pharmacological interventions, he takes doses of lactulose with
an optimum dose of 10 mL, Oromorph with doses of 2.5 mg for an interval of 4 hours, Senna with
levels of 15 mg, Amlodipine 5 mg according to the instructions of his medical advisors. Oramorph
is often used in children post operation for management of pain and is often used in addition to
ibuprofen and NSAIDs to reduce the severity of pain (Gan, Kamani, Daniel, 2017).
For the generalised pain, the nurse will use the PQRST to score the pain, Effective
management of pain will help to improve the quality of life of the palliative care patient, Mr. Ravi.
whenever his in pain for proper intervention like pharmacological intervention is important.
Precautions should be taken for checking the side effects inclusive of respiratory depression. The
doses should be monitored using interventions like PQRST which ascertains the severity of the pain
experienced by Mr Ravi. According to Downing et al.(2015), PQRST method is effective for the
assessment of pain which would help in the selection of proper pain medication and subsequent
evaluation of the response for treatment.
The decrease in the severity of the pain will help Mr. Ravi to verbalise his pain and thereby helping
the nurses to detect and treat pain effectively. The goal is to attain from score 3 to 0 or 1. Non-
pharmacological intervention for the effective management of pain will include proper use of the
music therapy. Music therapy will help to attain distraction and thereby helping to manage pain
(Gutgsell et al. 2013).
Significance of members of the Multidisciplinary Team (MDT)
A multidisciplinary team is required for the proper care and support given to Mr Ravi post
his ailments. According to William et al. (2014), establishment of proper multidisciplinary team
should be formed which is finally integrated with primary and secondary forms of care.

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Firstly, Mr Ravi have not been able to leave his bed and would need the help of his walking
stick. Thus, a district nurse is required for the care of Mr Ravi. The main work of the district nurse
would be to help Mr Ravi in his physical movements helping him to walk and enhance his mobility.
Moreover, she would also require to control and monitor his physical movements and help him in
carrying out the functions involving physical movements. District nurses in UK helps in
enhancement of the care package alongside the support of other members of the MDT. The district
nurse among with her nursing team would provide intensive support and enhance the care package
which would include valuable input from the psychologist and the psychotherapist. District nurses
fall under the purview of home healthcare. The duties of the district nurse would be provision of the
necessary advice as well as care regarding fluid balance, mobility, pain management for Mr Ravi.
The District nurse would also ensure the necessary treatment of Mr Ravi within time.
Mr Ravi also shown symptoms like ascites due to which there has been fluid accumulation
in his body, along with symptoms like inadequate urinal flow. From research studies it has been
seen that application of various interventions for ascites involved in liver problems have been
helpful in improving the quality of life (Lai et al.2014). Thus, a proper dietician is required who
would help in monitoring the fluid intake of Mr Ravi and plan his food intake in such a way that the
input and output of body fluids are maintained and urinal flow occurs properly. According to
Malbrain et al. (2014), interventions for limiting the total cumulative fluid balance have been
related to improved outcomes. Measurement of the abdominal girth would serve fruitful as it is an
effective method of diagnosis and helps in monitoring fluid build-up in the abdomen. The dietician
would also help in monitoring the levels of ascites through measurement for abdominal girth and
monitoring of the urine specific gravity. Moreover, the dietician would help in monitoring the
various signs of infection like fever, increased malaise along with elevate white blood cell count.
Maintenance of a fluid balance chart is necessary for monitoring his fluid balance.

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The multidisciplinary team would require a psychologist for helping him overcome
anxiety and introduce measures of reducing them. Since Mr Ravi have been facing difficulties in
moving from his bed to his chair an occupational therapist would be required who would help Mr
Ravi recover , develop, and improve the skills which are required for his working and daily living.
According to Hammell (2015), occupational therapist blend critical thinking while providing care
and provide an effective client centred care. For helping Mr Ravi with his mobility, a
physiotherapist would facilitate his movements. Proper monitoring of the doses are required for the
control of side effects and concerns should be raised during any problem faced by Mr Ravi
regarding the dose of the medications.
Depending on the level of ascites from low to mild ascites, management should include salt
restrictions along with diuretic therapy. Since there has been a significant amount of fluid loss due
to ascites, he should be treated with therapeutic paracentesis succeeded by colloid volume
expansion as well as diuretic therapy.
Conclusion
Thus from the following paragraphs it can be concluded that nursing interventions are of
primary importance while considering the conditions of the patients. In the given scenario, Mr Ravi
is an old man who has been suffering from alcoholic liver diseases due to excessive alcoholic
consumption. The use of frameworks for nursing and the implementation of the strategies in
nursing models help in the proper formulation of an effective care plan. The two basic nursing
problems which have been considered in the case of Mr Ravi are cultural isolation and fluid
imbalance. According to the reports of Mr Ravi, he has been experiencing excessive fluid retention
in the form of ascites. There has been an imbalance in the amount of fluid taken and lost from his
body thus requiring proper interventions reducing the symptoms for the escalation of health of Mr
Ravi. Thus the proper introduction of pharmacological as well as non-pharmacological
interventions will enhance the mental and physical condition of Mr Ravi alongside the decision

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making processes which will help in the formulation of an effective care plan based on the
requirements of Mr Ravi. Special attention given to his treatment based on the palliative care unit
will help to fulfill the given outcome.

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Appendix
Findings from the 1)
Objective
assessments
Alcoholic liver disease
Irregularities in sleep,
excess ascites
drainage,
Symptoms of
Jaundice, Itchiness in
Skin
Generalised pain in
the lower abdomen,
Tearful,
No permission for
entering religious
Problem 1:
Generalised pain in
the liver
Ascites which
causes discomfort in
the upper abdomen
Low food intake
Reduced urination
Restlessness
Agitation
Anxiety
After few
hours, Ravi
will
experiences
low pain in the
abdomen
Pain will be
observed
through
assessment
tools like PAIN
scores
Monitoring of Vital Signs
Performance of pain assessment for reducing complications regarding generalised pain
Encouragement of verbalization of the feeling of pain
Mental trauma- Interventions for providing assurance to Mr Ravi and his condition
Proper monitoring of the output and input of fluid
Restriction of fluid intake

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places
Cannot walking
without help of a
walking stick
Low food intake
Passes less
urine(oliguria)
Delay in major and
minor healing of
wounds
2) Subjective
assessments
Guilty of excessive
drinking
Imbalance of nutrients
Sleeplessness
Belief in spirituality
and life after death
Dysfunction of Kidney
Framework used:
Roper Logan Tierney
Maintenance of a
safe environment- Mr
Ravi lives with his wife
and has two children
Communication- He
has not shown any
difficulty in
communication and
can convey his own
Problem 2:
Ascites as a result of
alcoholic liver
disease
Manifested by
jaundiced
appearance, nausea
, restlessness
sleeping problems
Nutritional
imbalance
Prolonged time of
healing
After 12 hours
of
interventions
he will
experience
stabilised fluid
levels,
Urination will
be normalised
Decreased
abdominal
Administration of laxatives
Provision of ice chips of reducing thirst as Mr Ravi is suffering from fluid restriction
Restriction of the food intake and introduction of high protein drinks.
Introduction of pharmacological as well as non-pharmacological interventions
Provision of palliative care for improvising the dose of opioids for relieving pain
Reduced quality of skin, itching

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problems. He do not
suffer from hearing
problems
Breathing- No such
difficulties observed
Eating and drinking
Very low food intake
Feeling of Nausea all-
round the day
He is underweight and
suffers from diabetes
Elimination
He suffers from
oliguria
Thrugh the help of his
wife he passes bowels
twice a day
Washing and
Dressing
No problems noted.
Exhausted noted after
strenuous activities
Mobilisation
He cannot walk long
distances without the
help of a walking stick
Work and play
He believes in
religious theories and
is not allowed to enter
pain

20NURSING
the temple
Expressing Sexuality
Mr Ravi lives a normal
life with his wife and is
looked after by her
Sleeping
He suffers
irregularities in sleep
and is restless most of
the time
Moreover he is tired
after doing small tasks
Death and dying
He is concerned about
spiritual issues and
currently struggling
with his health
condition
He believes in life after
death
Two nursing
problems are
Cultural isolation
Generalised pain and
fluid imbalance
Other assessment
tools used
Waterlow score
NEWS score

21NURSING
APIE
Activities of daily living
Evaluation
From the assessments pain scores will be reduced after showing vital signs
Fluid imbalance will be stabilized and amount of food intake will increases after nursig interventions
After more than eight hours, urination rates will be normalised
Skin integrities will be reduced

22NURSING