final case pre(liver cirrhosis

8/4/2019 Final Case Pre(LIVER Cirrhosis

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In partial fulfillment of the RequirementsIn

NCM-101

RELATED LEARNING EXPERIENCE

A

CASE STUDY

On

LIVER CIRRHOSIS

At the

ECHAGUE DISTRICT HOSPITAL

SUBMITTED BY:

Ephraim Ablan

Mary Aileen Asajar

Dianne Melvin Buscagan

Rosemarie CamposanoAllyssa Marie Idorita

Elaine Marjorie Figarola

Neilborn Lutrania

Korina Sirajani

Maria Claudette Usita

SUBMITTED TO:

Abraham Nicolas, RN, MSN

(Clinical Instructor)


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INTRODUCTION

Cirrhosis is a condition in which the liver slowly deteriorates and malfunctions due to

chronic injury. Scar tissue replaces healthy liver tissue, partially blocking the flow of blood

through the liver. Scarring also impairs the livers ability to

control infections remove bacteria and toxins from the blood process nutrients, hormones, and drugs make proteins that regulate blood clotting produce bile to help absorb fatsincluding cholesteroland fat-soluble vitamins

A healthy liver is able to regenerate most of its own cells when they become damaged. With

end-stage cirrhosis, the liver can no longer effectively replace damaged cells. A healthy liver is

necessary for survival.

ETIOLOGY

Cirrhosis is commonly caused by excessive drinking of alcohol, drug reactions, prolonged

exposure to toxic chemicals, parasitic infections and repeated bouts of heart failure with liver

congestion.

CAUSATIVE AGENT

Alcohol, drugs, toxins and infections, autoimmune hepatitis, Nonalcoholic fatty liver disease

(NAFLD), chronic hepatitis C and Chronic hepatitis B and D

CLINICAL MANIFESTATION

Compensated

Intermittent mild fever Vascular spiders Palmar erythema (reddened palms) Unexplained epistaxis Ankle edema Vague morning indigestion

Flatulent dyspepsia Abdominal pain Firm, enlarged liver Splenomegaly


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Decompensated

Ascites Jaundice Weakness Muscle wasting Weight loss Continuous mild fever Clubbing of fingers

Purpura (due to decreased plateletcount)

Spontaneous bruising Epistaxis Hypotension Sparse body hair White nails Gonadal atrophy


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REVIEW OF RELATED LITERATURE

The most important risk factor associated with liver cancer iscirrhosis, a condition that precedes 80 percent of all liver cancers.

The most common cause of cirrhosis is chronic hepatitis B, acondition that afflicts about 10-12 percent of all Filipinos. Chronic

Hepatitis B is the main reason liver cancer incidence in the

Philippines is high. Other possible causes of cirrhosis are hepatitis

C infection and alcoholism.

The human liver is the largest single organ in the body andconsists of parenchymal cells, which metabolize, detoxify,

synthesize, and store nutrients. Normal functioning of these cells

depends on their proper organization. Cirrhosis, the final common

pathway for a variety of liver diseases, occurs when excessive

fibrosis results in the conversion of normal liver architecture into

structurally abnormal nodules.


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Cirrhosis is irreversible and can be life threateningit is a publichealth concern because of its associated mortality and morbidity.

The only available and definitive treatment is liver

transplantation. Cirrhosis is, however, preventable in most cases.The cumulative probability of clinical decompensation was 22% at

1 year and 54% at 3 years after cirrhosis developed.

The cumulative survival rate was 92% at 1 year and 78% at 5 yearsin patients with compensated cirrhosis.


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PATIENT PROFILE

Patient Name: Mr. MA

Age: 45 y/o

Sex: Male

Address: Purok 2 Diaraw, Jones, Isabela

Civil Status: Single

Occupation: Farmer

Religion: Roman Catholic

Birth Date: March 5, 1965

Birth Place: Burgos, Isabela

Date of Admission: August 17, 2010

C/c: Body weakness

Noted sign of abdominal enlargement

Conscious

Attending Physician: Ma. Cristina A. Ventura


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LABORATORY RESULTS

ABDOMINAL ULTRASOUND

The liver is enlarged with a liver span of at least 17.0cm. It shows coarse echotexture and

lobulated margins. The intrahepatic and extrahepatic ducts are not dilated (CBD=45mm).

Moderate amount of ascites is seen in the perihepatic, perisplenic, both paracolic gutters, and

pelvic cavity.

The gallbladder is minimally distended with suggestive tiny medium level echoes within.

Pancreas and spleen are unremarkable.

Only the proximal portion of the abdominal aorta is visualized. It is unremarkable with no

aneurysms noted.

Both kidneys are normal in size (RK=10.6 *5.1*5.2cm. LK=10,0*5.3*5.0cm) and parenchymal

echogenicity. No stones or hydronepphrosis seen. Cortical thickness measures RK=9.0mm.

LK=6.6mm.

The urinary bladder is minimally distended. The wall is normal in thickness.

REMAKS:

HEPATOMEGALY WITH LIVER CIRRHOSIS MODERATE ASCITES MINIMALLY DISTENDED GALL BLADDER WITH CHOLESTEROLISIS

STEPHEN ISIDRO MD

Radiologist Ultrasound


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HEMATOLOGY

PARAMETERS NORMAL VALUES RESULTS Interpretation

Heb Male 140-70 147 polycythemia, congestive heart failure,

obstructive pulmonary disease, high altitudes

Female 120-60

Hct Male .40-.51 .44 in anemia, leukemia, cirrhosis,hyperthyroidism

Female .37-4.5

WBC X109/L 5.0-10.0 15.4 Leukocytosis is an abnormal high WBC.

Bacterial infections often cause leukocytosis by

stimulating neutrophils to increase in number.

RBC X1012/L

Platelet X109/L 140-440

Neutrophils % 55-65 85 60% to 70% ( in acute infections)

Lymphocytes % 25-40 15 20% to 25% ( antibody reactions)

Monocytes % 2-8

Eosinophils % 1-3

Band or Srab 2-5

Mila Amor V. Reyes MD, FPSI

Anatomic & Clinical Patho


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GORDONS FUNCTIONAL PATTERNS

Health perception and health

management

Before Hospitalization During Hospitalization

Mr. MA doesnt told his SO (s) ifever he got sick.

The patient perceive as long as hefeel alright he consider his selfhealthy.

It was July 2010 he started complaining theenlargement of his abdomen. And reported he

defecated for many times and he was rushedto the hospital.

Nutritionalmetabolic

Pattern

Mr. MA is found of drinkingalcoholic drinks even without

intake of food he stated that Sa

isang araw dalawang long-neck,

emperador kasama ang mga

kaibigan ko nag-iinuman as

verbalized by the patient

Mr. MA had eat the food he wanted as orderby doctor that his diet as tolerated except the

day he had the ultrasound.

Pattern of elimination The patient experience loose bowelmovement more or less 10X defecation/day.

After voiding the patient experience dizziness

Activity-Exercise Pattern Mr. MA is a farmer, verbalized bythe patient nakakapagod talaga

trabaho sa bukid, minsan madali

akong mapagod

Mr. MA stays at his bed and gets up from hisbed when he feel urge of defecation.

Sleep-rest pattern The patient experience difficulty ofsleeping, due every afternoon he

drink alcoholic drinks with his

colleagues.

The patient also experiences difficulty ofsleeping due to the environment.

The patient looks tiredly.


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Cognitive-perceptual pattern The patient is behaved especiallywhen he is drunk. Never injured

anyone especially when he is

drunk.

The client feels dizzy after he defecated andfeels uncomfortable.

Self perception-self concept

pattern

The patient doesnt show any feelings of fearor anxiety. He jokes around as if nothing is

wrong, but after defecating his mood change,

he looks irritable and uncomfortable. The patient has a enlarge abdomen. He is

uncomfortable with his appearance and his

mobility

Role- relationship pattern The patient is the third child in six siblings, thepatient stated the eldest and second eldest

always done the family decision. So, he has no

big responsibilities in the family.

Sexuality-reproductive

pattern

The patient verbalized that he is still single.Coping stress-tolerance

pattern

The patient cope with his problemby drinking alcoholic drinks with

his friends and doing his vices like

smoking for the patient it helps in

his problem.

The patient is covert he solveproblems by himself.

He sleeps or lay on the bed to rest.

Value-belief pattern The patient is Roman Catholic. At their homethey are oriented with their religion and

according to the patient they have strong

devotion.


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NURSING HEALTH HISTORY

Patient MA verbalized that this is his first time to be hospitalized because before he

never had been hospitalized. The common illness they may have are common colds, cough and

fever.

Present Medical HistoryWas the date of confinement of August 17, 2010 the patient MA. According to the

patient he observes the usual enlargement of his abdomen and frequent defecating so

he was rushed to the hospital and admitted.

Family Health HistoryAccording to the patient the usual illness in their family are asthma and hypertension.

RR: 36cpm

CR: 128bpm

BT: 39.6 C

PR: 141bpm

Bowel Sounds 3spm

Abdomen: 33cn length

84cm width

A grade 6 change smoker Alcoholic drinker

General appearance: the patient with D5W 1L at 16 hours hooked at left arm. The patient can

tolerate sitting and lying position and infusing well but after the patient defecated he looks

pale, discomfort and felt dizzy.


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PHYSICAL ASSESSMENT

BODY PART ASSESSED TECHNIQUE USED NORMAL FINDINGS ACTUAL FINDINGS INTERPRETATION

SKIN

NAILS

HEAD

Inspection Palpation Palpation Palpation

Palpation

Inspection Inspection Palpation

Varies from light todeep brown

Uniform; withinnormal range

Moisture in skin folds No abrasions or other

lesions; freckles ,

some birthmarks,

some flat and raised

nevi

When pinched, skinsprings back to

previous state

Convex curvature;angle nail with 160

Highly vascular andpink

Prompt return of pinkor usual

color(Generally less

than 4 sec)

Color : Light brown Skin temperature : warm Moisture: Slightly dry Presence of lesion and scars.

Good skin turgor

Angle nail 160 Color : Slightly pinkish

Good blanch Capillary test

NORMAL

ABNORMAL due to increase of

body temperature

ABNORMAL due to dryness of theskin

ABNORMAL due to interruption

in skin integrity

NORMAL

NORMAL

NORMAL

NORMAL


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Skull

SCALP

HAIR

EYES

EYEBROWS ANDEYELASHES

EYELIDS LACRIMAL

Inspection

Palpation

Inspection

Inspection

Inspection Inspection

Inspection

Inspection

Palpation

Rounded; smoothskull contour

Smooth, uniformconsistency; Absences

of nodules or masses

Canthus of the eye isapproximately in line

with the upper tip ofthe ear

No infection orinfestation

Evenly distributed Thick hair and silky,

resilient hair

Hair evenlydistributed and

symmetrically aligned

Skin intact; nodischarges and

discoloration

No edema or

Normocephalic ; smooth skullcontour

No masses, nodules anddeppresions

Canthus of the eye isapproximately in line with the

upper tip of the ear

Absence of infection orinfestation

Evenly distributed Thin hair and not brittle ,

slightly dry

Normal outer, symmetricalwith the outer eyebrow and

eyelashes even distribution of

hair with lesion on the upper

part of the eye. Skin intact; no discharges and

discoloration

Not swollen/no tenderness

NORMAL

NORMAL

NORMAL

NORMAL

NORMAL

NORMAL

NORMAL

NORMAL

NORMAL


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APPARATUS

CONJUNCTIVA

SCLERA

PUPILS

EARS

AURICLES

NOSE

FACIAL SINUSES

MOUTH

LIPS


Inspection

Inspection

Palpation

Inspection Inspection Percussion

Inspection

tenderness

Shiny, smooth andpink or red

Colorless , shiny andsmooth

Black in color ; PupilEqually Round,

Reactive to Light and

Accommodation

Color same as facialskin

Mobile, firm and nottender; pinna recoils

after it is folded

Symmetric andstraight

Not tender; nodischarge ; mucosapink

Not tender

Pale Yellowish or jaundice

Black ; PERRLA

Color same as facial skin

Mobile, firm and not tender;pinna recoils after it is folded

Symmetric and straight Not tender; no discharge ;

mucosa red in the left nostril

Not tender

Dark brown

ABNORMAL due to lack of oxygen

ABNORMAL due to liver disorder

NORMAL

NORMAL

NORMAL

NORMAL

NORMAL

NORMAL

ABNORMAL due to smoking


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BUCCALMUCOSA

GUMS

TEETH

TONGUE

GAG REFLEX

PALATE ANDUVULA

NECK

Inspection

Inspection

Inspection

Inspection


Inspection Palpation

Uniform pink/browncolor ;

Pink color, moist,smooth, and soft

Pink gums

32 teeth; smooth,white, shiny tooth

enamel

Pink color; cenralposition, moves

freely; no tenderness

Present Light pink, smooth,

soft palate;

Lighter pink hardpalate, more irregular

texture;

Uvula positioned inmidline of soft palate

Muscles equal in size;head centered

Lymph nodes not

No sores and red color, moist,smooth, and soft

Dark brown gums

(+) dentures at upper and lower gums

Red color; central position,moves freely; no tenderness;

smooth with no palpable

nodules

Absent Red , smooth, soft palate; Red hard palate, more

irregular texture

Uvula positioned in midline ofsoft palate

Muscles equal in size; headcentered

No scars and mass; nopalpable lymph nodes;

trachea is at the center

NORMAL

ABNORMAL due to smoking

ABNORMAL due to it may cause

lesion

NORMAL

ABNORMAL it may indicate

problems with glossopharyngeal

NORMAL

NORMAL

NORMAL

NORMAL

NORMAL


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THORAX

(Anterior)

ABDOMEN

PERIPHERAL VASCULAR

SYSTEM

ARMS

REFEXES

Auscultation

Inspection

Auscultation

Percussion

Palpation

palpable

Vesicular andbronchovesicular

No evidence ofenlargement of liver

or spleen

Audible sounds,absence of arterial

bruits, absence of

friction rub

Tympany over thestomach and gas-filled

bowels; dullness over

the liver and spleen,

or a full bladder

Symmetric pulsevolumes; Full

pulsation

Clear breath sounds

Has evidence of enlargementof liver or spleen;

-Abdomen size: 33cmlength and 84 cm width

Bowel sound 3spm, RUQ

Dullness at 4 quadrant of theabdomen

Presence of radial pulse andbrachial pulse; no edema

NORMAL

ABNORMAL due to unusual

enlarge abdomen

ABNORMAL due to decrease of

motility

ABNORMAL due to large dull

areas

NORMAL


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TRICEPS REFLEX PATELLAR REFLEX

MOTOR FUNCTION

FINGERS TOTHUMB

Percussion Percussion +2 normal response

+2 normal response

Rapidly touches eachfinger to thumb with

each hand

+2 +2

Normally touches each fingerto thumb with each hand

NORMAL

NORMAL

NORMAL


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ANATOMY

Vital organ present in vertebrates and some other animals. Reddish brown organ with four lobes with unequal in size and shape. Lies below the diaphragm in the thoracic region of the abdomen. Weighs 1.4-1.6 kg (largest internal organ). Connected into two large vessels, hepatic artery (carries blood from the aorta) portal

vein (carries bloodcontainingdigested nutrients).

The two blood vessels subdivide into capillaries which then lead to a lobule.FUNCTIONS

Has major role in metabolism produces bile which is important to digestive process. Serves as storage of nutrients for later use or processed in various. Detoxification, protein synthesis, production of biochemicals necessary indigestion. It produces bile, an alkaline compound which aids in digestion, via the emulsification of

lipids.

Produces albumin the major osmolar component of blood serum. The liver synthesizes angiotensinogen, a hormone that is responsible for raising the

blood pressure when activated by renin an enzyme that is released when the kidney

senses low blood pressure.

The liver is responsible for immunological effects- the reticuloendothelial system of theliver contains many immunologically active cells, acting as a 'sieve' for antigens carried

to it via the portal system.

The various functions of the liver are carried out by the liver cells or hepatocytes.

Biliary Terr The term biliary tree is derived from the arboreal branches of the bile ducts. The bile produced in the liver is collected in bile canaliculi, which merge to form bile

ducts.

Intrahepatic (within the liver) bile ducts, and once they exit the liver they are consideredextrahepatic (outside the liver).

The cystic duct from the gallbladder joins with the common hepatic duct to form thecommon bile duct.


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Synthesis: protein produce and secreted water

o A large part of amino acid synthesiso The liver performs several roles in carbohydrate metabolism:

Gluconeogenesis (the synthesis of glucose from certain amino acids, lactate orglycerol). Note that humans and some other mammals cannot synthesize glucose

from glycerol.

Glycogenolysis (the breakdown of glycogen into glucose ) Glycogenesis (the formation of glycogen from glucose) (muscle tissues can also

do this)

o The liver is responsible for the mainstay of protein metabolism synthesis as well asdegradation


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NURSING CARE PLAN

ASSESSMENT DIAGNOSIS PLANNING INTERVETION RATIONALE EVALUATION

Subjective:

Mainit ang

pakiramdam ko as

verbalized by the

patient.

Objective:

RR: 36cpm CR: 128bpm BT: 39.6C PR: 141 bpm

Hyperthermia r/t

increased

metabolic rate

manifested by

increase in body

temperature above

normal range.

Within an hour of

nursing

interventions the

clients body

temperature will

decrease at 37.5C.

The nurse will:

Monitor vital sign.

Provide to the clienta TSB.

Promote surfacecooling by means of

removing excess

linens and dressing, if

there is.

Maintain bed rest

Promote a cool andcalm environment

Administerantipyretics as

ordered by the

doctor

To have baseline ofthe patients vital sign

For heat loss byevaporation and

conduction.

For heat loss byradiation and

conduction.

To reduce metabolicdemand.

For a restfulenvironment for the

patient.

To treat underlyingcondition.

Within 1 hour of nursing

interventions the patient

body temperature

decreases as evidenced by

a body temperature of

37.5C and the client

reported being

comfortable

-GOAL MET-


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Administerreplacement fluids

and electrolytes

Provide high-caloriediet

Discuss importanceof adequate fluid

intake

To support circulatingvolume and tissue

perfusion

To meet increasedmetabolic demands

To preventdehydration


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ASSESSMENT DAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective:

Minsan hindi ako

makahinga lalo na pag

busog ako as

verbalized by the

patient.

Objective:

Increasemetabolic rate

CR: 128bpm RR: 36cpm Shortness of

breath

observable

when he speak

Impaired

spontaneous

ventilation r/t

compression of

diaphragm

manifested by

shortness of

breath, increase

cardiac rate andincrease

respiratory rate

Within an hour of

nursing

interventions the

client will Re-

establish effective

respiratory pattern

via individual ability

as evidenced by

decrease inrespiratory rate

and cardiac rate

The nurse will:

Monitor vital sign Assess spontaneous

respiratory pattern,

noting rate, depth,

rhythm, symmetry of

chest movement, useof accessory muscles.

Elevate head of bed ifpossible

Coach client to makeslower, deeper

breaths, practice

abdominal breathing,

and assume position

of comfort.

Instruct client in use ofenergy-saving

techniques duringcare activities.

For baseline data To measure work of

breathing. To monitor

if there is complication

may occur.

To alleviate dyspneaand to the facilitate

oxygenation

To maximizerespiratory function

To limit oxygenconsumption

Within an hour of

nursing interventions

the patient establish

effective respiratory

pattern via individual

ability as evidenced by

decrease in respiratory

rate and cardiac rate.

-GOAL MET-


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ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective:

Lagi akong nagdudumi

as verbalized by the

patient

Objective:

More or less 10times

defecation perday

Bowel sound: 3sounds/min

Altered elimination

pattern r/t

compression of

large intestine and

increase of bilirubin

manifested by

More or less 10

times defecation

per day.

Within an hour of

nursing

intervention the

client will re-

establish normal

pattern of bowel

functioning as

evidenced by

decrease ofdefecation per day

at least 7 times of

defecation per

day.

The nurse will:

Monitor vital sign Ascertain onset and

pattern of diarrhea,

noting whether acute

or chronic.

Restrict solid foodintake as indicated.

Provide for changes indietary intake.

BRAT diet:

Banana, Rice, Apple, Tea

Encourage oral intakeof fluids containing

electrolytes.

Administermedications if ordered

by the Doctor.

For baseline data For baseline data

comparison

To allow for bowelreduced workload.

To avoid foodsubstances that

precipitate diarrhea.

To supplementelectrolytes and fluid

loss.

To decrease motilityand minimize fluid

losses as possible.

After an hours of nursing

intervention the client

had established partial

pattern bowel functioning

as evidenced by decrease

number of defecation, 7

times of defecation per

day.

-GOAL MET-


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SUBJECTIVE:

Ang masyadong

malaki ang tiyan ko

as verbalized by the

patient.

OBJECTIVE:

Self-negatingverbalization

measurementof abdomen:

34cm length

84cm width

Situational low self-

esteem r/t current

situational challenge

to self-worth

manifested by self-

negating and low

self-confident

Within 1 hour of

nursing

intervention the

client will:

o Acknowledgefactors that

lead to

possibility of

feelings of

low self-

esteem.

o Demonstrateself

confidence

by setting

realistic

goals and

actively

participating

in life

situation.

The nurse will:

Indentify basic sense ofself steam of client,

image client has of self

Determine clientsawareness of own

responsibility fordealing with situation,

personal growth, and so

fort

Assist client to problemsolve situation,

developing plan of

action and setting goals

to achieve desire goals

to achieve desire

outcomes

Provide feedback ofclient self negatingremarks/behaviour,

using I-messages it.

Encourage involvement

In order to the patientto know what

particular reasons of

his low self esteem.

In order the patient tobe aware of the

problem that broughthim to low self-

esteem.

enhancescommitment to plan

optimizing outcomes

To allow the client toexperience differentview

the patient will be

Within an hour of nursing

intervention the client

will:

A. Acknowledge factors

that lead to possibility of

feelings of low self-

esteem.

B. Demonstrate self

confidence by setting

realistic goals and actively

participating in life

situation.

As evidenced by positive

outlook from his current

condition.

-GOAL MET-


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in decisions about care

when possible.

Encourage use ofvisualization guided

imaging, and relaxation

to promote positive

serve of self.

Convey confidence inclients ability to copewith current situation.

aware in terms of his

Health care.

In order to the patientnot to lose hope

In order to the patientto cope up from hiscondition.


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Subjective:

hindi ko alam na sakit

napala ito, napansin ko

lang na masyado ng

lumalaki ang tiyan ko as

verbalized by the patient

Objective:

Patientsverbalization of

unawareness

Inadequate selfawareness about

his health

condition

Deficient

knowledge r/t

unavailability of

data presented

manifested by

patients

inadequate

awareness about

his present healthcondition.

Within an hour of

nursing intervention

the client will

verbalize

understanding of

health condition

process as evidenced

by participating in

learning process

The nurse will:

Determine clientsmost urgent need

from clients and

nurses view point

State objectivesclearly in learnersterms

Determine clientsmethod of accessing

information and

include in teaching

plan

Begin withinformation the

client already knows

and move to what

the client does not

know progressing

from simple to

complex

Provide positivereinforcement

Identifies informationthat can be addressed

at a later time

To meet learners needs

To facilitate learnings

Limits sense of beingoverwhelmed

Encouragescontinuation of efforts

Within an hour of

nursing interventions

the patient had

verbalized

understanding of

health condition

process as evidenced

by participating in

learning process.

-GOAL MET-


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Identify motivatingfactors for the

individual

Let the patient bealert to signs and

avoidance

To have interest in thelearning process

In order for the patientto be aware


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DISCHARGE CARE PLAN

MEDICATION

Explain thoroughly to Patient MA the importance of immediate or continuous treatmentof liver cirrhosis. Encourage patient MA to take his medicine/s religiously or as needed

depending on the Physicians order.

EXERCISE

Encourage patient MA to have some form of exercise within his potential ability tominimize complications. Teach the client for a change of lifestyle. Advice patient for

moderate drinking alcoholic drinks and moderate smoking and if possible step by step

excluding any vices that would make the health problems be worst.

TREATMENT

Advice patient MA to seek for diagnostic evaluations, if ever conditions got worse. Thesuccess of treatment on convincing the patient of the needed to adverse completely to

the therapeutic plan. This may include rest, lifestyle changes, adequate dietary intake

and the elimination of alcohol.

HYGIENE

Let the Patient MA be informed the importance for extensive personal hygiene and aspossible patient MA would perform extensive personal hygiene as part of his newchange lifestyle.

OPD CHECK-UP

Instruct patient to follow indicated or schedules follow up check-up for faster recovery.DIET

Encourage patient MA to consume a balance diet specifically: BRAT diet (Banana, Rice,Apple, and Tea). Sodium restriction will continue for a considerable time, if not

permanently.

SPIRITUAL

Encourage Patient MA to maintain a good relationship with his personal God forSpiritual Graces.

SOCIAL

Advise Patient MA to continue his social life as long as he knows limitations especiallyregarding activities.

final case pre(liver cirrhosis

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