NURSING CARE PLAN

ON
CHRONIC LIVER DISEASE
RELATED AIH

SUBMITTED TO: SUBMITTED BY:

Dr.Sunita shrivastva Sangeeta yadav
Reader M.Sc. (N) 1st year
CON, CON,
ILBS ILBS.

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Introduction about self:
My name is Sangeeta Yadav, M.Sc. Nursing 1ST year student of ILBS Nursing College. I
was posted to 4floor pvt ward, Phase-II of the hospital from 08/04/24 to 12/04/24 as a
part of my clinical experience.
Introduction about client:
Ms. Neha , 4 years old resident of bagpat, UP. She was admitted on 5th April 2024 in 4 floor
pvvt ward the diagnosis of CLD AIH related to liver transplant.
Reason for selecting this topic for care note:
I found my client’s case interesting and therefore, I selected CLD AIH as my topic for a
nursing care plan. This will enable me to learn the comprehensive care required by such
patients and therefore enable me to develop and refine my nursing care skills including the
management.
Informant: Patient’s Mother and with the help of medical records.
Socio Demographic Profile
● Name: Ms. Neha
● Age: 4 years
● Gender: Female
● Religion: Hindu
● Marital status: Unmarried
● Educational background: LKG
● Occupation: Student
● Current Address: baghpat , UP.
● Date of admission: 5/4/2024
● Diagnosis: CLD AIH
● Ward: 4 floor pvt ward
● Bed number: 02
● Treating physician: Dr. Vinod Arora

Chief Complaints:
Condition on admission:
● Jaundice index 3 month
● Abdominal distension index 1 month
● Black coloured stool 1 episode

History of present illness:

Neha 4-year female child has an index presentation 3 month back with jaundice which was
acknowledged by pigmented stool and dark colored urine, non- pruritic. It was associated
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with gradual abdomen distension. No history of oedema, no history of fever/rash, no history
of joint pain, no history of change in behavior, no history of CAM intake.
Past health history
Past health history is not significant.
Past surgical history
Past surgical history is not significant.
Personal history
● Diet and nutrition: Vegetarian, Appetite is adequate.
● Elimination patterns: Normal elimination patterns.
● Sleep pattern: Adequate
● Activity and rest pattern: Patient only perform passive exercises.
● Substance use: No history of substance use.
● Leisure activity: Patient talks with his family.
● Sexual and reproductive history: No sexual and reproductive history.
● Medication history: Patient was taking medications for jaundice on OPD basis.
● Allergic reaction: No H/O any drug allergy/ food allergy.
● Immunization: No H/O of immunization
Social history
● Birth history: Bagpat
● Residence: Bagpat
● Education: LKG
● Marital status: Unmarried
● Income: 55,000/month (Father)
Family history
● Type of family: Nuclear
● Total no of members: 3
● Number of dependents: 2
● Family pedigree:

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 Keys

Male Patient

Female

S.no Name Relation Age/sex Education Occupation Health

Status
1 Mr. Manoj Father 34 yr/male Graduate self Healthy
employed
2 Mrs. Mother 29yrs/female Graduate Housewife Healthy
Vidushi
3. Ms. Neha Patient 4 yrs/ female LKG Student Unhealthy

Family disease: No history of DM/HTN hypothyroidism/CAD/Cancer and any psychiatric

illness in the family.
PHYSICAL EXAMINATION
Date of physical assessment performed: 09/04/24
General appearance
● Body built: Moderate
● Nourishment: Well nourished
● Level of consciousness: Conscious
● Hygiene: Maintained
● Activity: Passive range of motion
Vital signs
S.NO HR Rhythm BP RR Temp SpO2

Day-1 98b/min SR 116/80mmHg 20 98.2F 99%

Day-2 96b/min SR 124/73mmHg 22 98.4F 100%

Day-3 98b/min SR 111/66mmHg 20 98.8F 99%

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Anthropometric Measurement
● Height: 116cm
● Weight: 21.8kg
● BMI: 16.20kg/m2
Head to Toe Examination
Skin
● Color: Skin is yellowish
● Texture: Skin is dry
● Temperature: 98.6F
● Lesions: No macules, papules, vesicles present
● Clubbing: Not present
● Edema: No Anasarca/ No pitting
Oedema Head
● Color of hair: Black
● Shape of skull: Normal
● Scalp: Clear
● Pediculosis: No pediculosis
● Texture: Texture is soft
● Hair distribution: Less
Face
● Shape: Symmetrical, Pale
● Oedema: No facial/Ocular edema
● Hydration: Face is hydrated
● Any abnormality: No any other abnormality
Eye
● Vision: No Myopia/ diplopia/ hypermetropia
● Eyebrow: Both eyebrow is in symmetrical shape
● Eye lashes: There is no evidence of eye infection
● Eyelid: Normal No stye/swelling/ptosis
● Eyeball: Eye ball is round in shape and not protruding/ Not
sunken/No exophthalmos.
● Conjunctiva: Pink/ no conjunctivitis
● Sclera: Yellow
● Cornea & Iris: Symmetrical
● Pupil: Pupil is reactive
● Lens: No opaqueness/ no crust formation
Ear
● Hearing: Patient is able to hear properly.
● External ear: Clear ear
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 ● Tympanic membrane: There is no perforation
● Discharge: No discharge from Ear
Nose and Sinus
● Nostrils: Nostrils are normal clean
● Nasal septal deviation: There is no septal deviation
● Discharge: No discharge is present from nose
● Any bleeding from nose: No bleeding is present
● Sinus: Sinus is normal
Mouth
● Lips: Symmetrical, dehydrated slight black in color, no
cyanosis.
● Odor of mouth: Halitosis is present
● Teeth: Yellowish discoloration of teeth
● Mucous membrane & gums: There is no swelling present
● Tongue: Dry
● Tonsils: No inflammation or ulceration of tonsils
Neck
● Nuchal rigidity: Not present
● Lymph node: No lymphadenopathy
● Thyroid gland: Not palpable
● Trachea: Midline
● Carotid pulse: Palpable/No distension is present
Chest:
● Scar: No scar present
● Symmetry: Symmetrical in shape
● Color: Normal skin color
● Lesion: No lesion
● Chest: Symmetrical in shape & no Barrel
chest. Axilla
● Redness: Not present
● Lumps: Absent
● Rash: Absent
● Lymph node: Not enlarged

SYSTEMATIC EXAMINATION
Neurological system

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 ● Coordination test: Normal
● Reflexes: Normal
● Test for sensation: Normal
● GCS: 15(E4V5M6)
Respiratory system
● Inspection: Symmetrical
● Barrel chest: Absent
● Breathing pattern: Normal
● Palpation: No tenderness
● Percussion: No free fluid present
Cardiovascular system
● Inspection and palpation: Tensed and Distended
● Auscultation: S1 and S2 normal, no murmur present
● Heart rate: 84b/m
● Pain: no chest pain
Abdomen
● Inspection : Distended and no scars noted
● Auscultation : Hypoactive bowel sounds
● Percussion : Dull, free fluid present
● Palpation : Soft, non-tenderness or rebound tenderness, guarding,
rigidity present, liver and spleen palpable below
costal
margin.
● Abdominal Girth : 34 cm

Genitalia & Rectum

● STD’s: Absent
● Any abnormalities: Absent
● Hemorrhoids: Absent
● Pelvic masses: Absent
● Rectal polyps: Absent

Extremities
● Movements: Voluntary movements are present
● Tremors: Absent
● Edema: Not present
● Reflexes: Present
● Varicose vein: Absent
● Clubbing of the fingers: Absent
● Calf muscle pain: Absent
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 ● Homan’s sign: Negative
Spine
● Spina bifida: Absent
● Scoliosis/kyphosis/lordosis: No scoliosis found
● Curvature: Normal
● Sacral region: No scoliosis found
Impression:
Abdomen was tensed and free fluid was present.
INVESTIGATION
1. Laboratory investigation
2. Radiological investigation
3. Others
Laboratory investigation
S. Specimen Name of The Patients Values Normal
No Investigation Values
08/4/24 09/4/24 10/4/24 (WithUnit) Remarks

1 Blood Hemoglobin 8.4 8.2 8.0 11 – 16 mg/dl Decreased

2 Blood Sr.Magnesium 1.8 1.9 1.8 1.7-2.8mg/dl Normal

3 Blood Sr.Calcium 8.8 8.4 8.6 8.4-10.2mg/dl Normal

4 Blood Sr.Bilirubin(T) 0.88 0.61 0.49 0.3-1.2mg/dl Normal

5 Blood (D)Bilirubin 0.4 0.2 0.1 0.2mg/dl Normal

6 Blood (I)Bilirubin 0.18 0.41 0.3 0.2-0.8mg/dl Normal

7 Blood AST 77 68 91 5-40IU/L Increased

8 Blood ALT 73 67 79 7-35IU/L Increased

9 Blood SAP 646 547 591 32-92IU/L Normal

10 Blood PT/INR 11.9/1.92 11.8/1.10 11/0.97 11.0/2-3 Normal

11 Blood TLC 15.8 11.2 11.9 4-11*10~9/L Increased

12 Blood Neutrophil 80.2 81.7 74.6 40-75% Increased

13 Blood Albumin 3.11 3.29 3.38 3.5-5.2mg/dl Normal

14 Blood Sr. Sodium 138 137.5 136.1 136-145mmol/L Normal

15 Blood Sr. Potassium 3.27 3.1 4.17 3.5-5mmol/L Normal

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 16 Blood Bicarbonate 17.2 19.9 20.2 23-29mmol/L Normal

17 Blood S.Cr. 1.78 0.99 0.87 0.6-1.31mg/dl Normal

Radiological Examination
Chest X-ray
Rotation is normal
Bilateral lung Parenchyma are clear
Both hila and mediastinum appear normal
Domes of diaphragm are normal
Bony cage and soft tissue are unremarkable
USG Abdomen
Impression: Chronic liver disease with findings suggestive of portal hypertension
Splenomegaly with prominent spleno portal axis and gross ascites.

Medications:
S.No Name of Drug Frequency Dose Route
1. Cefepime TDS 1gm IV
2. Inj Elores TDS 900mg IV
3. Albumin 20% OD 100ml IV
4. Methylprednisolone OD 40mg PO

Drug Dose Action Indications Contraindication Side Nursing

effects Responsibility
Cefepime 1gm Binds to Susceptible History of Oral -obtain CBC,
BD bacterial infections anaphylactic candidiasi renal function
IV cell wall due to reaction, s, mild test
membranes aerobic hypersensitivity, diarrhea, -monitor daily
, inhibits gram- renal transplant. vaginal pattern of
cell wall negative candidiasi bowel activity.
synthesis. organisms, s, nausea, -monitor I&O.
intra- allergic -
abdominal reaction,
infections, thrombop
UTI, hlebitis.
Pneumonia.

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Inj. Elores 1.5gm, Combinatio Used to Hypersensitivity Injection Perform C&S
IV,BD n of three treat various site tests prior to
medicines: types of reactions therapy.
Ceftriaxone bacterial (pain, Determine
, Disodium infections. It swelling, history of
edetate and prevents the redness) reaction.
Sulbactam. growth of Nausea Do not skip
Ceftriaxone the Vomiting any dose
is an microorgani Diarrhea and finish
antibiotic. sms that the course as
It works by cause the suggested by
preventing infection. the doctor.
the
formation Look for
of the rashes,
bacterial itching,
protective swelling and
covering shortness of
which is breath while
essential taking the
for the medicine.
survival of
bacteria in
the human
body.
Disodium
edetate is
an adjuvant
while
Sulbactam
is a beta-
lactamase
inhibitor.
They are
added to
reduce
resistance
and
enhance the
activity of
Ceftriaxone
against
bacteria.
Methylpred 40mg Methylpred Various Serious infections Oedema, Taper doses
nisolone OD nisolone is inflammator except septic hypertensi when
PO a synthetic y and shock or on, discontinuing
corticostero allergic tuberculous arrhythmi high-dose or
id with disorders, meningitis; viral, a, skin long-term
mainly rheumatoid fungal and atrophy, therapy to
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 glucocortic arthritis, tubercular skin bruising, allow adrenal
oid activity Ulcerative lesions; admin of hyperpig recovery.
and colitis live virus mentation
minimal vaccines.
mineraloco
rticoid
properties.
It decreases
inflammati
on by
suppression
of
migration
of
polymorph
onuclear
leukocytes
and
reversal of
increased
capillary
permeabilit
y

Nursing Management
Nursing Assessment
● Assess vital signs. Patients can have fever with chills, hypotension, or tachycardia.
● Review serum sodium and potassium levels, which may become depleted with
nasogastric suctioning or fluid shifts.
● Review serial WBC count and differentiation to evaluate the course of action.
● Assess tissue perfusion. Note level of consciousness, skin color and
temperature, pulses, and capillary refill.
● Assess hydration status: note skin turgor on inner thigh or forehead, condition
of buccal membranes, and development of edema or crackles.
● Assess the patient’s abdomen for resolution of rigidity, rebound tenderness, and
distention. Auscultate bowel sounds.
Nursing Diagnosis
● Acute pain related to discomfort due to surgical procedure as evidenced by
patients dull facial expression and verbalization.
● Imbalanced nutrition less than body requirement related to anorexia and dietary
restrictions secondary to disease condition.
● Activity intolerance is related to fatigue, lethargy and malaise secondary to disease
condition.
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● Risk for Impaired Skin Integrity related to altered circulation/metabolic state.
● Risk of Injury related to disorientation and immobilization.
● Risk of infection related to invasive procedure and stasis of body fluids.
● Impaired Skin Integrity related to accumulation of drainage; altered metabolic state as
evidenced by disruption of skin surface/layers and tissues.
● Ineffective Breathing Pattern related to decreased lung expansion as evidenced
by reduced vital capacity, apnea, cyanosis, noisy respirations.
● Fear/Anxiety related to Situational crisis; unfamiliarity with environment as
evidenced by Facial tension, restlessness.
● Knowledge deficit related to the condition and self-care related to disease condition.

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NURSING CARE PLAN
ASSESSMENT NURSING GOALS PLANNING AND RATIONALE EVALUATION
DIAGNOSIS IMPLEMENTATION
Subjective Data Acute pain To reduce the -Assess the level and location of To get baseline data to After the nursing
Patient verbalizes related to pain of the pain for baseline data and for plan interventions or to intervention, the
about the pain he discomfort due patient. evaluating the pain relief prevent further patient was able to
has while to surgical strategies. episodes. manage the tolerance
touching her procedure as - Assess for vital signs. To note the specific of pain.
abdomen. evidenced by changes.
patients dull
Objective Data facial expression - Administer analgesics agent as To reduce the episode
The patient is and prescribed to promote pain relief. of pain.
witnessed crying verbalization.
with pain and - To use diversional therapies to To divert the mind of
massaging his divert the mind of the patient by the patient to reduce
abdomen. venting the feelings. the discomfort.
T-98F
P-102 bpm -
R- 20 bpm
BP- 110/90
mmhg
Pain score-5/10

Subjective Data Activity To maintain the -Assess the level of activity To obtain baseline data. After nursing
Patient verbalizes intolerance is activity intolerance and degree of intervention, the
that she does not related to tolerance of the fatigue. patient started doing
want to walk or fatigue, lethargy patient. To maintain range of some range of motion
sit. and malaise - Assist with a physiotherapist in motion. exercises on his own.
Objective Data secondary to doing active passive exercises
and chest physiotherapy.
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The patient is disease -Provide a high calorie and high To improve fatigue
evidenced with condition. protein diet to the patient. and lethargy.
fatigue, lethargy
and malaise. - Administer supplemental
Vitamin therapy to the patient.

To reduce the -Patient vital signs are monitored To get the baseline data After regular nursing
Subjective Data Risk of Injury risk of injury to and kept under observation. of the patient. interventions, the
Patient verbalizes related to the patient. patient was relaxed to
and shouts that disorientation -Patient is provided with raised To reduce risk of injury some extent.
she will remove and side rails.
all the invasive immobilization.
lines. -Explored and expound the
Objective Data warning signs and usual patterns.
The patient is - Patient is given adequate rest
disoriented, not and avoided the stimulus which To reduce physical
able to sit or can precipitate the activity. stress.
move alone or -Administered medications on
without any time as prescribed by the
assistance. physician. To reduce the potential
risk of the next episode.

- Adhere to facility infection

control, sterilization, and
To prevent the aseptic policies and procedures.
patient from the
Risk of infection infection. - Review laboratory studies for - Established
related to the possibility of systemic mechanisms designed to
Subjective Data invasive infections. prevent infection.

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The patient is not procedure and Risk of infection is
verbalized stasis of body - Increased WBC reduced to some
anything as she fluids. - Examine skin for breaks or count may indicate extent.
was not much irritation, signs of infection. ongoing infection.
aware of his
present - Disruptions of skin
condition. integrity at or near the
Objective Data operative site are
There is a risk of - Apply sterile dressing. sources of
infection due to contamination to the
invasive wound.
procedures, - Prevents
drainage from the - Administer antibiotics as environmental
tubes. indicated. contamination of
fresh wounds.
- May be given
prophylactically for
suspected infection or
-Reinforce initial dressing and contamination.
change as indicated. Use strict
To prevent the aseptic techniques.
Impaired Skin patient from - Inspect wounds regularly, - Protects wounds
Integrity related impaired skin noting characteristics and from mechanical
to accumulation integrity. integrity. injury and
Subjective Data of drainage; contamination.
The patient altered - Early recognition of Skin integrity is
complains about metabolic state delayed healing or improved to some
itching present as evidenced by - Assess amounts and developing extent.
on the skin. disruption of characteristics of drainage. complications may
Objective Data skin prevent a more
serious situation.

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Mobilization is surface/layers - Decreasing drainage
absent, discharge and tissues. suggests evolution of
from the drainage healing process,
site. whereas continued
drainage or presence of
- Maintain patency of drainage bloody or odoriferous
tubes; apply collection bags over exudate suggests
drains and incisions in presence complications
of copious or caustic drainage. - Reduces risk of
- Monitor or maintain dressings: infection and
hydrogel, vacuum dressing. chemical injury to
skin and tissues.
- May be used to
hasten healing in large,
draining wounds/
fistula, to increase
patient comfort, and to
reduce frequency of
dressing changes.
- Assess the knowledge level by
To provide the asking questions.
patient’s
Knowledge mother with -Emphasize the importance of
deficit related to adequate maintaining the diet, frequent To get the baseline data.
Subjective Data the condition information. meals and restriction on fluids.
The patient’s and self-care
mother related to - Discuss the importance of Provides knowledge to
verbalized that disease infection prevention practices. patients. After the nursing
she doesn't know condition intervention the
what's going on patient has some
clarity regarding the

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with her -Identify signs and symptoms Minimize risk of other condition and
daughter. requiring notification of infections. treatment.
Objective Data healthcare.
The patient is Indicators of worsening
confused and conditions.
wants to know
the further
treatment.

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Nurse’s Progress Notes:
Date and Day Condition of Patient
Day 1 ● Vital signs of the patient recorded carefully.
● Hygiene of the patient is well maintained.
● Patient’s haemodynamic parameters charted on hourly
basis
● Medication administration done as per the orders by the
doctor.
● Assisted in changing the urinary catheter with the staff.

Day 2 ● Vital signs of the patient recorded carefully.

● Hygiene of the patient is well maintained.
● Medication administration done as per the orders by the
doctor.
● Maintained intake-output hourly chartings.

Day 3 ● Vital signs of the patient recorded carefully.

● Hygiene of the patient is well maintained.
● Medication administration done as per the orders by the
doctor.
● Maintained intake-output hourly chartings.
● Bed bath given and all dressings changed under
aseptic conditions.

DIET: High protein, normal diet is recommended for the client.

Health Education
● Diet : Patient was recommended to have a high protein diet.
● Physical activities and exercises: Patients were instructed to maintain daily activities
ROM exercise or walk as much as tolerated.
● Medications: Patient was explained well and enforce the importance and compliance
with medication
● Prevention of complication: Patient was taught the ways to keep the incision area
clean.
● Home care and follow up: Patient was instructed to look for any complications and to
follow up when required

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Conclusion:
I Sangeeta yadav student of M.Sc. Nursing 1st year was posted in 4floor pvt ward, . There I
took this patient Ms. Neha, 4 years old for my nursing care plan and is a known case of CLD
AIH. The patient was admitted with complaints of abdominal distension, jaundice, dark
colored urine.
I gave her 3-4 days care while preparing for this NCP and I came to know the disease
condition and correlate it with the book clinical manifestation, diagnostic evaluation and
Treatment. On my last day of patient care the patient 's condition was stable and shifted to
delux.

Bibliography:
1) Lippincott, manual of nursing practice, edition 8th publisher Jaypee brothers Pp.
1075-1077.
2) Brunner &Suddarth’s, Medical Surgical Nursing. 10th Edition: Pp-1113-1116.
3) PubMed:http://www.pubmed.org
4) Joyce M. black, eighth edition, volume 2, Medical surgical nursing.

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