15.Client Information Sheet
Student name: _Scott Watson_ Clinical Date: _02/20/07_ * Reminder: Do not remove the patient care summary or other documents from the hospital! Room/Bed Age: Gender: Marital Status: 632A 60 F Married Admit Date: 2/17/07 Reason for Admit: Pt presented to the ED with complaints of abdominal distention and pain along with bilateral lower extremity swelling and erythema for several weeks. Pt also has jaundice. Pt came into the ED for increasing jaundice and abdominal pain secondary to increasing distention of the abdomen. This has not been acute but has been an accumulative process.
Significant Medical History:
Significant for liver cirrhosis, diabetes mellitus type 2, alcohol abuse, and chronic pancreatitis. Pt states she has not been on medications for one year.
Tense ascites due to cirrhosis
Surgical Procedure and Date (if any at this admission):
Diet Ordered: Rationale: Diab-sodium control 1800cal, 2 gm NA Low NA to reduce fluid retention (ascites) Activity Level: Rationale: Bed rest To get rid of the fluid from lower extremities Lab Procedures ordered: (Results on back)
Xtra pink-draw & hold; LDH, peritoneal; Albumin, peritoneal; Protein total, peritoneal; Hemoglobin A1C; Culture bacterial, U midstream; Sodium, random UR Other Tests: (Results on back)
DUS: Paracentesis (Dx ascites)
DUS: leg-useven, bilateral, eval for DVT
Allergies: (Include reaction) Code Status: No known allergies Full code
LAB VALUES ON ADMIT, MOST RECENT AND NORMAL VALUES FOR THE INSTITUTION. INCLUDE INTERPRETATIONS FOR ALL ABNORMAL VALUES.
Admit 2/18/07 Recent 2/19/07High/LowNormal RangeRationale
Potassium3.82.7L3.5-5.5 mmol/lchronic hypokalemic acidosis common in pts w/ chronic alcoholic liver disease Sodium117124L135-147 mmol/lsecondary to fluid overload
Ammonia78H11-40 umol/linability of failing liver to convert ammonia to urea and shunting of intestinal blood bia collateral vessels. PATHOPHYSIOLOGY
Describe, in your own words, the pathophysiology as it relates to this client. Include etiology, signs and symptoms and medical plan of care. Be sure to include a brief description of all comorbid diseases. Be sure to include all references for this section and corresponding full APA format reference on the Reference Page. Do not limit yourself to the space allotted here—use as much room as you need! Cirrhosis is a chronic, serious disease in which normal configuration of the liver is changed, resulting in cell death. When new cells are formed, the resulting scarring causes disruption of blood and lymph flow. Although pathologic changes do not occur for many years, structural changes gradually lead to total liver dysfunction. Manifestations of cirrhosis are related to hepatocellullar necrosis and...