The measure of life is not its duration but its donation
Poornima1, Jency Nirmala2
1Staff Nurse, Kauvery Hospital, Tennur. Trichy, India
2Nursing Incharge, Kauvery Hospital, Tennur. Trichy, India
Abstract
Chronic liver disease is a progressive deterioration of liver function. Liver disease accounts for approximately 2 million deaths per year worldwide, 1 million due to complications of cirrhosis and 1 million due to viral hepatitis and hepatocellular carcinoma. A liver transplant is a surgery that removes a liver that no longer functions properly (liver failure) and replaces it with a healthy liver from a living donor. Organ donation is not a tragedy; it can be a beautiful mindset on life. In this article, we would like to share our best nursing care given to a CLD patient, and counselling regarding liver transplantation given to the family members.
Case Presentation
A 42-year-old gentleman, with alcohol dependence, came with the c/o abdominal distension for 10 days. He also had a loss of appetite, yellowish discolouration of the body, bilateral leg swelling and weight loss. He had taken native treatment prior to his coming to Kauvery Hospital. He had a fever and mild breathing difficulty, but no cough. No H/o decreased urine output-no known co-morbidities.
On examination, patient was conscious and oriented, afebrile, bilateral pitting pedal edema (+), icterus (+), PR: 102/min, BP: 110/80 mm Hg, RR: 28/min, SpO2: 89% in room air / 96% with 3 litres O2, CVS: S1 S2 (+), RS: NVBS, P/A: Distended.
Lab parameters are below:
Bilirubin:
- Total 21.8 mg / dl
- Direct 15.7 mg / dl
- Indirect 6.11 mg / dl
- PT time – 2.43 seconds
- Total Count – 13,800 / cc.mm
- Platelet count – 83,000 /cc.mm
- Sodium 121 mmol
- Potassium 3mmol
Abdomen scan reported paranchymal liver disease, cholilithiasis, bilateral pleural effusion, bilateral renal changes and ascites.
Nephrologist opinion was obtained to rule out HRS (Hepato renal syndrome). Pulmonologist opinion was obtained for pleural effusion and tapping was done. Radiologist opinion was obtained to treat ascites and was done.
Endoscopy revealed small oesophageal varices.
On evaluation, he was found to have Acute on Chronic Liver Failure (ACLF) coagulopathy, ascites with dysplastic nodule on liver. He needed liver transplant at the earliest.
He was treated with IV fluids, Albumin, IV antibiotics and other liver-supportive medications.
A hepatic surgeon opinion was obtained, CECT (contrast-enhanced computed tomography) abdomen, CEA (carcinoembryonic antigen) and CA 19- 9 (cancer antigen) were done. They showed chronic liver failure with multifocal enhancing nodules in both lobes, Ascites and Hepatomegaly were present.
Patient is hemodynamically stable, and planned for liver transplantation.
Health Promotion
Prevention is better than cure. Common risk factors for CLD include alcoholism, malnutrition, viral hepatitis, obesity, and right-sided heart failure.
Alcoholism must be treated. Urged patient to avoid alcoholic ingestion.
Hemodynamic Monitoring
Our team aggressively managed this patient. We did two hourly reassessments by using invasive technology that provided quantitative information about vascular capacity, blood volume, pump, effectiveness and tissue perfusion. We monitored the patient on non-invasive BP, pulse rate and quality, skin temperature and color, capillary refill time, pulse oximeter, and invasive when required Whenever the patient had any complaints, they were immediately managed. The patient had dyspnea (Spo2 below 90%, RR – 26 b/mint) due to ascites and pleural effusion. Fowler’s position and breathing exercises were explained to the patient
Strict monitoring of intake and output
The patient had poor excretion and poor oral intake due to multi-organ challenges (liver, abdomen, kidney) involved in this condition. Periodically we monitored intake and output and also monitored daily weight and abdominal girth to rule out edema and volume overload.
We educated the patient and family members regarding restrictions of fluid intake and output, closely monitored the amount and colour of the urine, and watched over monitored patient’s health status such as muscle cramping, weakness, lethargy, confusion etc. to rule out volume overload.
Monitoring the patient’s bleeding varices
The patient had a risk for bleeding tendency due to esophageal varices. We closely monitored hemorrhagic problems like bleeding tendency, hematuria, melena, hematemesis and anemia. Education was given to the patient and family members regarding the causes of bleeding and complications. The oesophageal banding plan was explained to the patient and family members.
Prevention of Pressure ulcers
Because of poor tissue perfusion and limited movement, pressure ulcers may develop, so our patient had a high risk of developing pressure injury so our team took measures to prevent that such as frequent position changes, restoring circulation with mobility and promoting adequate nutrition, WE assessed our patient’s skin frequently, provided meticulous skin care, monitored nutrition status and implemented pressure-relieving devices such as air mattresses. In spite of all these measures patient had mild skin pealing on the chin due to 48 h of prone position but healed within a week
Nutrition
For any patient to come out of their illness the nutrition part is very important. As this patient had severe oral ulceration, we had a challenge in the administration of feed. Nurses were focused on patient nutrition along with doctors, and dieticians to avoid hypoglycemia, nutritional deficiency etc. Our team had taken the challenge and provided good nutrition with adequate calories, and supported with IV fluids
Psychological support
Our team gave emotional and psychological support to the patients and family members, and provided the best communication and coordination with other team members; so, the patient and family members were satisfied and the patient’s health improved and attained positive outcomes.
Ambulatory and Home Care
The patient’s condition was explained to the family members- about the prolonged course and the possibility of life-threatening problems and complications. Supportive measures such as a diet and rest were given. Counselled on avoidance of OTC (over-the-counter) medicines (e.g. acetaminophen) and, more importantly, abstaining from alcohol. However, abstinence from alcohol is difficult for some patients but we explained clearly to the family members about the benefits of abstinence from alcohol.
All information was given to the caretaker about how to detect the early signs of rejection, other vital symptoms, rest, diet restrictions, improving the nutritional status, providing skin care, reducing the risk of injury, drug therapy, observation for bleeding, monitoring and managing complications.
Nurse as a good Counselor
Nurses play a very essential role in liver transplant counselling. Our patient was at the end-stage liver disease and needed liver transplant.
Liver transplant become a practical therapeutic option for many people. Annually nearly 20,000 people need liver transplants in India. About 15% in the country are receiving the surgery with success rate of up to 90% to 95%. Approximately 400 surgeries are carried out annually, majority of the transplants happen thanks to living donors.
Counselling is given to the family members regarding the need for a liver transplant, benefits, success rate, patient life expectancy, availability of living donor and availability of deceased donor, side effects, costs, pre-operative screening tests, Regular follow-up care are explained well. Almost the family members became clearly aware and confident about the success of the liver transplantation.
Finally, his wife gave her full consent and wholeheartedly agreed to donate part of her liver.
Conclusion
There is a large discrepancy between the number of patients who need liver transplants and the number of transplants being done in our country. With expertise available for both living donor liver transplantation (LDLT) and deceased donor liver transplant (DDLT), many of these patients can be offered a definitive treatment for their lethal liver disease. Early referral for liver transplant will help patients to explore their both options and choose their appropriate modality of treatment. For many patients liver transplant is necessary and lifesaving, but availability of donors is low. Donors of part of their liver are counselled that the part of the liver they lost would not only give a loved one a new life but would also regenerate,
Be an organ donor, Be a hero, Life is a gift, Pass it on!
Ms. Poornima
Staff Nurse
Ms. Jency Nirmala
Nursing Incharge