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Running Head: CASE STUDY #47 ANALYSIS
Case Study #47 Analysis
Kristen Tavares
University of New Hampshire
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CASE STUDY #47 ANALYSIS
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Case Study #47 Analysis
John Doe, approximately 50 years old, is admitted to your unit for observation from the
emergency department (ED) with the diagnosis of rule out hepatic encephalopathy with acute
alcohol (ETOH) intoxication. This man was sent to the ED by local police, who found him lying
unresponsive along a rural road.
Examination and x-ray studies are negative for any injury and you are awaiting the results
of the blood alcohol level (BAL) and toxicology tests. He has no identification and is not awake
or coherent enough to give any history or to answer questions. He is lethargic, has a cachectic
appearance, does not follow commands consistently, and is mildly combative when aroused. He
smells strongly of ETOH and has a notably distended abdomen and edematous lower extremities.
He has a Foley catheter and is receiving an intravenous (IV) infusion of D5 ½ NS with 20 mEq
KCl and 1 ampule of multivitamins at 75 mL/hr.
Admitting Orders are: IV D5 ½ NS with 20 mEq KCl at 75 mL/hr; add 1 ampule
multivitamins to 1 L of IV fluid per day; Insert Salem Sump nasogastric tube and attach to low
continuous suction; Insert Foley catheter to gravity drainage; Elevate HOB at 30 to 45 degrees at
all times; Check all stools for occult blood; Lactulose (Cephulac) 45 mL PO qid. Call if diarrhea
develops; Abdominal ultrasounds in AM; Vitamin K (AquaMEPHYTON) 10 mg/day IV x3
doses; change to PO when alert and able to swallow; Vitamin B1/ thiamine 100 mg/day IV;
change to PO when alert and able to swallow. Vitamin B9 /folic acid 0.4 mg/day IM; Vitamin B6
/pyroxidine 100 mg/day PO; Labs: CBC with differential, BMP, liver function tests (LFTs),
PT/INR and aPTT, serum ammonia (NH3) now and in AM; Once patient is alert and able to
swallow, may have low-protein diet. Observe for any difficulty swallowing, and offer assistance
with meals as needed; Call house officer for any sign of gastrointestinal (GI) bleed; delirium
tremens (DTs); systolic blood pressure (BP) over 140 or less than 100 mm Hg; diastolic BP less
CASE STUDY #47 ANALYSIS
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than 50 mm Hg; or pulse over 120 beats/min.
Cirrhosis of the liver is a representation of end stage chronic liver disease that can result
from alcoholism (Porth, 2007). It is the conversion of normal liver into nodules that have
proliferating hepatocytes encircled by fibrosis (Porth, 2007). The formation of nodules are a
combination of regenerative activity and constrictive scarring (Porth, 2007). The fibrous tissue
forms constrictive bands that alter the flow in vascular channels and biliary duct systems of the
liver (Porth, 2007). The disruption of vascular channels can lead to portal hypertension and more
complications like ascites (Porth, 2007). Portal hypertension is causes by increased resistance to
flow in the portal venous pressure (Porth, 2007). Dilation and pressure of the venous channels,
along with the collateral channels opening and connecting the portal circulation with the
systemic venous circulation leads to ascites (Porth, 2007). Ascites is when the fluid in the
peritoneal cavity is increased (Porth, 2007). This is caused from portal hypertension, salt and
water retention from the kidneys and decreased colloidal osmotic pressure from the impaired
synthesis of albumin by the liver (Porth, 2007). Treatment of ascites involves dietary restriction
of sodium and administration of diuretics, and possible administration of potassium supplements
to prevent hypokalemia (Porth, 2007). Spider animas are a clinical manifestation of liver failure
(Porth, 2007). They are involved in the skin and consist of central pulsating arterioles, which
allow smaller vessels to radiate (Porth, 2007).
Hepatic encephalopathy can occur from acute or chronic liver disease, but many patients
do not seek help until late in the disease when complications develop. According to Bleibel
(2012), “chronic liver disease and cirrhosis affect more than 5.5 million people in the United
States and studies have indicated that overt hepatic encephalopathy affects 30-45% of patients
with cirrhosis and a higher percentage may be affected by minimal degree of encephalopathy”
CASE STUDY #47 ANALYSIS
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(p. 301). Hepatic encephalopathy is a complication of cirrhosis of the liver. It involves the central
nervous system and is characterized by neural disturbances, which involves a mental status
change; confusion, seizures, and can lead to a coma. Although the exact cause is unknown,
neurotoxins, like ammonia, accumulate in the blood because the liver is unable to detoxify it.
When this happens, ammonia moves into the general circulation and from there to the cerebral
circulation. A large protein meal can also worsen hepatic encephalopathy, hence putting John
doe on a low protein diet. (Porth, 2007). In order to treat liver failure in John Doe’s case, he will
need to eliminate the use of alcohol, adjust his diet to low protein to reduce the amount of
ammonia, and fix his electrolyte balance.
Hepatic encephalopathy can occur in 4 stages. According to Chaney, (2015) “the West
Haven Criteria (WHC) is most often used to grade HE, with scores ranging from 0-4 (4 being
coma)” (p. 301). Hepatic encephalopathy can be called two types, Covert (CHE) relating to stage
1 and 2 because sometimes the disorientation can be unclear and Overt (OHE) relating from
stage 2 and 4 because there are more definitive symptoms. Stage two involves lethargy and
asterixis. Stage three involves somnolence with arousability, disorientation with bizarre
behavior. Stage four involves of the patient being in a coma. (Chaney, 2015) Using this scale and
comparing it to John Doe’s symptoms, it can be seen that he is in stage three. John is difficult to
arouse and is sometimes combative.
John Doe needs immediate alcohol detox in order to sober him up to receive a valid
identification and past medical history from him. A nurse should keep John’s head of the bed at
least above 30 degrees to decrease risk of aspiration or airway problems. One should complete a
full head to toe assessment and insert a Salem Sump Nasogastric tube with low continuous
suction to observe what type of fluid comes out of the distended abdomen, as well as measure the
CASE STUDY #47 ANALYSIS
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abdomen daily. One should hang a bag of IV D5 ½ NS with 20 mEq KCL at 75 mL/hr. One
should insert a Foley catheter to monitor John’s output. A nurse should watch for a bowel
movement in order to receive an occult blood test to test for a GI bleed. A nursing assistive
personnel (NAP) can be delegated to get vital signs, make sure John is comfortable, cleaned up,
safe and record his input and output.
John was ordered Vitamin K, AquaMEPHYTON; Vitamin B1, thiamine; Vitamin B9
,folic acid; and Vitamin B6, pyroxidine. A nurse should administer Vitamin K immediately
considering that John is intoxicated and his liver is not absorbing vitamins sufficiently. Vitamin
K will promote clotting factors in order to prevent spontaneous bleeding and correct his
prolonged clotting. Vitamin B1 should be administered immediately because if a patient is
thiamine deficient it can lead to Wernicke’s encephalopathy and John is being discharged to rule
out Hepatic Encephalopathy, therefore it should be given preventatively. Vitamin B9 should be
given in order to correct any problems with anemia. Vitamin B6 should be given to prevent skin
lesions and the opening of mucous membranes (Hinkle, 2010).
John Doe’s lab work taken in the Emergency department has come back and his Blood
Alcohol Level is 320 mg/dL, and the blood ammonia (NH3) level is 155 mcg/dL. His total
protein is 5.2 g/dL and albumin is 2.1 g/dL. John’s blood alcohol level is indicating that he is
severely intoxicated and is at risk for respiratory or fatal consequences (Dalwari, 2014). John’s
blood ammonia level exceeds the normal range of 15- 45 mcg/dL drastically (Martin, 2015). An
increased ammonia level is considered a major etiologic factor in the development of
encephalopathy (Hinkle, 2010). John’s protein and albumin levels are below normal range due to
malnourishment (Martin, 2015). In order to alter John’s ammonia levels, Lactulose can be
administered. Lactulose is an ammonium detoxicant and can be given in a case of
CASE STUDY #47 ANALYSIS
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encephalopathy. Its mechanism of action is to trap and expel the ammonia in the feces (Hinkle,
2010). As a patient that is admitted for possible rule out of hepatic encephalopathy with acute
intoxication, it is important to remember that patients with liver problems are not able to
adequately absorb vitamins, because they are processed through the liver. Therefore, these
vitamins need to be administered as a supplement.
Case Study Progress
While you are getting John Doe settled, you continue your assessment. Neurologic
findings: PERRL (Pupils Equal, Round, Reactive to Light), moves all extremities, but patient is
sluggish, pulling away during assessment, and follows commands sporadically. Cerebrovascular
findings: Pulse is regular without adventitious sounds. All peripheral pulses are palpable at 3+
bilaterally; 3+ pitting edema in lower extremities. Respiratory assessment: Breath sounds
decreased to all lobes, no adventitious sounds audible, patient not cooperating with cough and
deep breathing, and Spo2 at 90% on room air. Gastrointestinal assessment: Tongue and gums are
beefy red and swollen, abdomen is enlarged and protuberant, and abdominal skin is taut and
slightly tender to palpation. Salem Sump NGT is patent, connected to LCS with small to
moderate greenish drainage; bowel sounds positive with NGT clamped. Genitourinary
assessment: Foley to gravity drainage, with 75 mL dark amber urine past 2 hours. Skin: Pale on
torso and lower extremities; heavily sunburned on upper extremities and head. Skin appears thin
and dry. Numerous spider angiomas are found on the upper abdomen with several dilated veins
across abdomen. Vital Signs: 120/60, 104, 32, 99.1 degrees Fahrenheit (37.3 degrees Celsius).
An abnormal part of John’s assessment was finding spider angiomas, dilated abdominal veins,
peripheral edema, and a distended abdomen. The significance of the edema is related to
hypoalbuminemia from decreased hepatic production of albumin. Spider angiomas are small
CASE STUDY #47 ANALYSIS
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vessels that are often associated with cirrhosis of the liver (Hinkle, 2010). The significance of
this is that considering the patient’s history is unknown and is currently intoxicated and has an
extremely increased BAL, this patient most likely has problems with his liver. The significance
of the dilated abdominal veins and abdominal distention is due to fluid build up. The clinical
name for this finding is ascites. Ascites can be caused from portal hypertension, which increases
capillary pressure and obstruction of venous blood flow from a damaged liver. If the liver is
impaired, it may not be able to metabolize aldosterone, which then would increase sodium and
water retention by the kidney. All of these shifts can cause fluid to move into the peritoneal
space (Hinkle, 2010). According to Fullwood (2014), the abdomen should first be inspected for
signs of injury, like bruising or wounds, and for prominent veins. The size, symmetry and
distention should be measured. Next, auscultation of the abdomen should be done to listen for
gurgling sounds along with palpation afterwards to see if the patient has any pain or tenderness.
Percussion is the last part of the assessment to figure out the amount of fluid that is in the
stomach. Dullness can be heard around the flanks in the supine position. The fluid from the
ascites should be tested and labs should be run to test the albumin and red blood cell count, and
for infection. A paracentesis can be done to drain fluid from the abdomen, and from there is can
be collected in a specimen cup and brought to the lab (Hinkle, 2010).
John Doe has been admitted to the ICU lethargic and has a cachectic appearance. As
defined by Medicine.net (2012), cachectic is physical wasting with loss of weight and muscle
mass, which can be caused by a major chronic progressive disease. A nurse would be concerned
about John’s nutritional status, mainly involving his electrolyte balance, his protein intake,
vitamin deficiencies, and malnutrition related to alcoholism. Objective findings regarding his
nutritional assessment are that he is receiving Lactulose, which is a laxative that can affect his
CASE STUDY #47 ANALYSIS
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electrolyte balance. Also, John’s cachectic and intoxicated appearance allows a nurse to
understand that he may not be giving himself enough nutrition. Another objective finding could
be beefy, red tongue and gums, which could indicate pernicious anemia considering the liver is
unable to properly process his red blood cells. John also has a nasogastric tube in place, which if
necessary can be used for tube feedings for his malnutrition.
Although John’s protein level of 5.2 g/dL is so low, he should not be on a high protein
diet because this would increase his levels of ammonia, which could then worsen hepatic
encephalopathy and lead to a coma (Hinkle, 2010). Therefore, a priority intervention in regards
to John’s nutritional status would be to get a nutritional assessment by a dietician. While waiting
for this process, John should be kept on a low protein diet and if necessary a diuretic should be
further given to help treat his fluid retention.
Case Study Progress
A nurse is continuing her assessment and implementation of the admission orders.
Another nurse comes to help and states, “Why are we wasting time with this wino? He isn’t
worth the time or money. Why don’t they let him die?” A nurse could respond to this other
nurse’s remark by stating that as a nurse our job is to help and care for each patient as much as
we can until there are no further interventions possible. As there is no medical history obtained
from this patient, one cannot assume that this patient is a do not resuscitate and do not intubate.
As a nurse, one should try their hardest and not give up on the patient, even if they may have
made poor decisions in life, one should not judge them or care for them any differently than
another patient. Also, it would be important to let this nurse know that cirrhosis is not always
related to alcoholism, and that she should not assume that since he is acutely intoxicated that he
is an alcoholic.
CASE STUDY #47 ANALYSIS
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Safety and preventing injury is an important priority when it comes to John Doe’s care as
he may be withdrawing from alcohol. Areas of injury risk that may be involved with John Doe
are a change in his mental status to delirium or confusion and also due to the detox, it could
result in seizures, as well as balance and coordination difficulty (Vera, 2013). John is also at a
risk for bleeding, especially if he falls. Actions that a nurse can take to ensure John’s safety
would be to maintain seizure padding on the bedrails, bed in lowest position, call bell within
reach, assisting with ambulation, and reorient patient if needed. Medications, like anti-anxiety,
benzodiazepines, and magnesium sulfate can be given to reduce seizure activity. While
monitoring John Doe for signs and symptoms of alcohol withdrawal and delirium tremens, it is
found that he is restless, has tremors, and a low-grade fever. Other symptoms of severe delirium
tremens are hallucinations, somnolence, vomiting, extreme diaphoresis, and tachycardia (Martin,
2015). Electrolyte imbalances can be a big risk for falls related to alcohol withdrawal, as well as
seizures. If the patient is standing up and suddenly falls to the ground due to a seizure, serious
injuries can occur, including bruising, head injuries, and more.
Case Study Progress
During John Doe’s hospitalization, a staff psychiatrist evaluates him for mental decline
associated with alcohol abuse and dependence, including Korsakoff’s psychosis. Effects of
chronic alcohol abuse that are associated with Wernicke’s encephalopathy include confusion,
nystagmus, and ataxia. Effects that are associated with Korsakoff’s psychosis are confabulation,
the inability to learn and short-term memory loss. (Campellone, 2014).
Case Study Progress
John Doe survives a rocky course of hepatic encephalopathy and near-renal failure. After
27 days, including a week in the intensive care unit (ICU), he is discharged to a drug and alcohol
CASE STUDY #47 ANALYSIS
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rehabilitation facility. He is employed as a longshoreman; fortunately, his insurance covers his
month of in-house intense rehabilitation.
According to Scott Snyder (2015), “the most recent data from the CDC reveals the
overall mortality from chronic liver disease and cirrhosis in the United States in 2013 was 36,427
persons. The age groups with highest mortalities were 45-54 and 55-64. Of persons who died of
chronic liver disease and cirrhosis in 2013, 65% were male” (p. 34). John Doe is a fifty-year-old
male who is at a high risk of mortality. The nurse should recommend for John to continue
rehabilitation in order to become and stay sober to achieve a longer survival rate.
In a study by Mohammad (2012), it was found that combination therapy of Rifaximin and
Lactulose is recommended for the prevention of hepatic encephalopathy, especially after already
having an episode previously. It was shown to improve mental status and ammonia levels.
According to Medscape, Rifaximin is an antibiotic that can be helped to treat people with hepatic
encephalopathy. It works by inhibiting the growth of ammonia producing bacteria in order to
reduce the serum ammonia level. Based on the literature, John needs to become motivated to
give up alcohol long term to be able to live a more meaningful life, instead of being in the
hospital often for complications.
Overall, an acute case of hepatic encephalopathy, if not found and treated quickly, can
cause deterioration of the liver and put the patient into a coma. Elevated ammonia levels can
indicate that the liver is not able to convert it to urea. John should be put on a low protein diet to
reduce his ammonia levels and decrease the chance of worsening the case of hepatic
encephalopathy. John Doe should receive lactulose to cause him to move his bowels in order to
also remove ammonia that is stored. Vitamin supplements should be given to replace what
John’s liver is unable to metabolize, for example: folic acid, thiamine, pyroixidine,
CASE STUDY #47 ANALYSIS
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AquaMEPHYTON, and a multivitamin. Liver function tests and blood draws should be done
daily in order to see John’s progress. Neurological assessments are important to make sure that
John’s mental status does not worsen. A nasogastric tube can be inserted to help suction out the
fluid build up in John Doe’s abdomen. If enough is not being suctioned out, a paracentesis can
further be implemented to provide relief. In John Doe’s case, safety is extremely important
because he is acutely confused and intoxicated. Important interventions for John include
detoxification of alcohol; watching for aspiration risk; assessing him head to toe; assessing for
seizure risk, and treating the cause of his acute encephalopathy and liver failure.
CASE STUDY #47 ANALYSIS
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Reference
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Gastroenterology, 18(5), 301-309 9p. doi:10.4103/1319-3767.101123
Campellone, J. V., MD. (2014, February 24). Wernicke-Korsakoff syndrome: MedlinePlus
Medical Encyclopedia. Retrieved March 29, 2016, from
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Chaney, A., Werner, K. T., & Kipple, T. (2015). Primary Care Management of Hepatic
Encephalopathy: A Common Cirrhosis Complication. Journal For Nurse
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CASE STUDY #47 ANALYSIS
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Martin, L. J., MD. (2015, May 3). Total protein: MedlinePlus Medical Encyclopedia. Retrieved
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