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

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