Cirrhosis Case for Printing

7/29/2019 Cirrhosis Case for Printing

1/12

LEVEL 4 . NCM 105 . 2 ND SEM SY 2011-2012 P a g e | 1

Level 4CASE PRESENTATION

2nd Semester SY 2011-12

I. Statement of Objectives

A. General Objectives

This case analysis aims to increase the understanding and knowledge of student nurses on how

to care for patients with Liver Cirrhosis, ascites effectively and efficiently.

B. Specific Objectives

Specifically, this case analysis aims to:

1. Define Liver Cirrhosis and its effects to the body as a whole;

2. Illustrate the pathophysiology of Liver Cirrhosis and in relation to the signs and symptomsspecifically observed in the client;

3. Describe and identify the common signs and symptoms of Liver Cirrhosis;

4. Discuss the medical and surgical interventions for the management of Liver Cirrhosis;

5. Formulate appropriate nursing care plans suited for the client based on the assessment findings;

6. Identify care measures to be given to the patient and family to promote continuity of care and

independence after discharge.

II. Clients Profi leName :N.S.

Age :43

Birth date :January 20 1968

Sex :Male

Ethnic Background :Pangasinense

Civil Status :Married

Address :1st Kayang St. B.C.

Religion :Roman Catholic

Occupation :Vendor

Admitting Diagnosis :Liver Cirrhosis, ascites secondary to alcohol liver disease

Final/Principal Diagnosis : Liver Cirrhosis, ascites secondary to alcohol liver disease

Admitting Physician :Dr. Curameng

Date and Time Admitted :January 18 2012


2/12


III. Chief ComplaintAbdominal pain, DOB

IV. History of Present IllnessThe patients condition started 1 month prior to admission when the patient noted his abdomen to be

slightly distended, and he was easily fatigued. He did not seek consultation and ignored the signs and

symptoms. He did not take any medication. Two weeks prior to admission the patient had decreased

appetite and had a feeling of constant fullness. He sought consult at Assumption Medical Diagnostic

Clinic and had an ultrasound revealing ascites and multiple cholelithiasis. The patient was advised for

admission but he refused.

One day prior to admission, the patients abdominal distention increased in size, the patient complained

of difficulty of breathing prompting medical consultation, hence his admission to BGHMC (Baguio

General Hospital and Medical Center).

V. Past Medical HistoryThe client had Hepatitis A on the year 1990 while he was working as a construction worker, he did not

seek medical treatment and he claims the disease resolved on its own. The client was not involved in

any major accident or contracted any other major disease. He experienced minor ailments such as

fever, flu, and cough and colds, which were treated with over the counter medication. He has not been

hospitalized prior to his admission to BGHMC.

VI. Family Health HistoryThe client does not have any familial history for any disease.

VII. Developmental HistoryOur client is a 43 year old male, based on the developmental stages of Eric Erikson; he is under

generativity vs self-absorption. In this developmental stage work is most crucial. Erikson observed that

middle-age is when we tend to be occupied with creative and meaningful work and with issues

surrounding our family. Also, middle adulthood is when we can expect to "be in charge," the role we've

longer envied. The significant task is to perpetuate culture and transmit values of the culture through

the family (taming the kids) and working to establish a stable environment or relationship. Strength

comes through care of others and production of something that contributes to the betterment of

society.

Our client works as a cook. He and his wife manage their business in order to sustain their daily living,

but after being hospitalized due to the serious illness he developed a sense of uselessness. Patient

quoted : pabigat na ako sa pamilya ko, di namin alam kung saan kami kukuha ng pangastos, pati mga

anak ko tumigil ngayon sa pagaaral para my katulong ang asawa ko na umaasikaso sa negosyo namin,

but because of support and love of his family he continues to have hope for himself.

VIII. Social and Environmental HistoryThe patient lives with his family in a 2 room apartment approximately 75 square meters. The apartment

is a four story building made up of concrete and generally strong materials. The patient claims to be

friendly with their neighbors and does not have any disputes with family members or non-family

members. He does not have any problems interacting with his family. He has some drinking buddies

who drink with him within the vicinity almost every night.


3/12


IX. Lifestyle and Health PracticesThe patient started drinking alcoholic beverages at the age of seventeen. He stated that he drinks on

average one to two bottles of beer almost every night. He is fond of eating the fatty meat leftover from

what he prepares for their mami and arozcaldo business especially along with the beer. The patient

claims he does not smoke and neither does his family members. The client does not perform any

exercise. He does not take any vitamins. Most ailments are dealt with by taking OTC medication.

X. Health Assessment

A. General SurveyThe patient is receiving oxygen via cannula at 2-3 Lpm. With ongoing IVF of PNSS 1L regulated at KVO

infusing well at the right hand. Patient is ambulatory but needs some assistance in performing ADL.

Patient is conversant and cooperative. Drainage is noted at the right lower quadrant where peritoneal

fluid is drained regularly by the physician. The patient has a distended abdomen.

B. Head to Toe Assessment1. Head Normocephalic. Hair is black, and well distributed, thick and smooth. Oily, no lice

and dandruff, no lesions noted. No tenderness upon palpation.


4/12


2. Eyes Symmetrical, pupils are equally round, equally reactive to light andaccommodation, able to follow penlight with gaze, palpebral and fornixconjunctiva are moist and light pink. No verbalized problems in vision. Able todistinguish colors. With slight yellowing of the sclera.

3. Ears Able to understand and hear spoken language correctly, with minimal cerumenbuild-up on the ear canal. With intact tympanic membrane. No lesions noted.There is no pain or tenderness upon palpation of the auricles and the mastoid

process.4. Nose and Sinuses Nose is patent, septum is located midline, no flaring noted, able to distinguish

scent, and no episodes of epistaxis, sinuses are not tender on palpation.

5. Mouth Incomplete set of adult teeth, with dental carries noted at molar teeth, no malaligned tooth, no dentures. Oral mucosa is moist and pinkish, no lesions noted,tonsils are not inflamed, uvula is located midline.

6. Neck ROM intact (able to change direction of head with ease and without complaints of pain); carotid pulse are bilaterally symmetrical, full and strong pulses, jugular veinis not distended. Thyroid is located midline, no enlargement noted.

7. Chest: A) LUNGS Symmetrical chest wall expansion noted, with regular rate and depth of inspiration(23 cpm). Neither crackles nor wheezing noted upon auscultation. RR: 23cpm

B) Cardiac Adynamic precordium; PMI located at 5th ICS LMCL. Normal rate, regular rhythm,no murmur noted, With BP= 140/90 mmhg, PR= 92 bpm. With bounding pulse.

8. Abdomen With paracentesis site noted at the right lower quadrant. Rigid, globular, withabdominal girth of 93 cm, with dullness to percussion on the RUQ. With tympanicsounds at the LUQ. No masses palpable. With bowel incontinence. Withhypoactive bowel sounds.

9. Uro-genital No complaints of dysuria, with polyuria.

10. Musculoskeletal No tremors noted, with muscle wasting noted. With muscle grading of 4/5 and fullROM, weakness noted.

11. Integumentary With good skin turgor, no wounds, no evidence of dryness. Flushed appearance,skin warm to touch. T=36.8 C. No diaphoresis. With edema of lower extremities.

XI. DiagnosticsDiagnostic Procedure Definition Normal reference values Actual values

Peritoneal fluid Differential

and cell count

01/19/12

5:30pm

Doctors remove fluid

(ascites) from the

abdomen to analyze its

composition and determine

its origin, to relieve the

pressure and discomfort it

causes, and to check for

signs of internal bleeding

This procedure should beperformed whenever an

individual experiences

sudden or worsening

abdominal swelling or

when ascites is

accompanied by fever,

abdominal pain, confusion,

or coma.

RBC: none

WBC: less than 300/cumm

RBC: 3/cumm

WBC: 15/cumm

Blood in the fluid may

indicate an injury.

The WBC count is less than

300/cumm therefore

infection is ruled out.

Hematology

01/20/12

A clotting test, the

prothrombin time is done

to test the integrity of partof the clotting scheme.

Familiarly called the "pro

time," the test is the time

needed for clot formation

after a substance called

thromboplastin (+ calcium)

has been added to plasma.

PT: 11.5-15.5 seconds

PTT: 26-36 seconds

PT: 18.9 seconds

PTT: 43.1 seconds

Both PT and PTT areprolonged which may

indicate that the liver is not

functioning properly since

the liver is the organ for

synthesis of Prothrombin


5/12


Prothrombin is a

coagulation (clotting)

factor needed for the

normal clotting of blood.

There is a cascade ofbiochemical events that

leads to the formation of

the final clot. In this

cascade, prothrombin is a

precursor to thrombin.

Because prothrombin

comes before thrombin, it

is called prothrombin.

Gram stain and Acid Fast

Stain

01/20/12

Gram staining (or Gram's

method) is a method of

differentiating bacterialspecies into two large

groups (Gram-positive and

Gram-negative).

Bacteria with an acid-fast

cell wall when stained by

the acid-fast procedure,

resist decolorization with

acid-alcohol and stain red,

the color of the initial

stain, carbol fuchsin. The

genus Mycobacterium and

the genus Nocardia are

acid-fast. All other bacteria

will be decolorized and

stain blue, the color of the

counterstain methylene

blue.

The acid-fast stain is an

especially important test

for the genus

Mycobacterium. Besides

the many saprophytic

forms of mycobacteria,

there are two distinctpathogens in this group:

M. tuberculosis, the

causative organism of

tuberculosis, and M.

leprae, the causative agent

of leprosy. Mycobacterium

tuberculosis (the tubercle

bacillus) causes

tuberculosis, although

atypical species of

Mycobacterium may

occasionally causetuberculosis-like infections,

especially in the debilitated

or immunosuppressed

host. Mycobacterium

avium-intracellulare

complex (MAC), for

example, frequently causes

Negative for

microorganisms

GS: No microorganisms

seen

AFS: Negative for acid fastbaccili

The results indicate that

there is no infection.


6/12


systemic infections in

people with HIV/AIDS.

Chest PA

01/18/12

a projection radiograph of

the chest used to diagnose

conditions affecting the

chest, its contents, and

nearby structures. Chestradiographs are among the

most common films taken,

being diagnostic of many

conditions.

Normal organs, no

enlargement or fluid

accumulation

Nodularized opacities are

seen on both lower lobes

Heart is not enlarged with

atheromatous aorta

Pulmonary vascularmarkings are within normal

Visualized osseus

structures are

unremarkable

Pneumonitis both lower

lobes

CBC

01/18/12

Test done to count blood

components.

WBC: 5-10x10^9/L

RBC:4.69^6.13x10^12/L

HGB: 140-180 g/L

22.01x10^9/L

3.07x10^12/L

102 g/L

.

Low RBC maybe indicative

of injury or bleeding, low

RBC will also mean low

HGB.

Blood Chemistry

01/18/12

Albumin:3.4-5.0 g/dL

HDL:40-60 mg/dL

LDL:o-200 mg/dL

Triglycerides:0-150 mg/dL

AST:15-37 U/L

1.80 mg/dL

23.46 mg/dL

130 mg/dL

142.22 mg/dL

132 U/L

Results indicate low

albumin levels indicative of

liver damage and may also

be causing ascites because

of low oncotic pressure.

High AST values is

indicative of liver disease

Ultrasound

01/04/12

is an ultrasound-based

diagnostic medical imaging

technique used to visualize

muscles, tendons, and

many internal organs, to

capture their size,

structure and any

pathological lesions with

real time tomographic

images.

Normal organs, absence of

inflammation and excess

fluids.

Hepato-splenomegaly

Ascites

Multiple cholelithiasis

Sonographically normal

pancreas, kidney and

urinary bladder


7/12


XII. General Pathophysiology of Liver Cirrhosis

Precipitating

factor:

Predisposing

factors:Chronic alcohol

Ascites

Structural disorganization and

collapse

Loss of secretory function and

disturbance of excretor

Hypoalbuminemi

Depressed

glycogen

synthesis and

inhibited normal

hepatic cell

metabolism

Decreased synthesis of

prothrombin protein

Prolonged prothrombin time

Portal

hypertension

Build-up of

bilirubin

Collateral circulation

is created

Impaired

metabolism

Impaired

liver function

Injury and

Scarri

Long-term injury of

Loss of liver

Increased

peritoneal

Risk for impaired skin

integrity r/t presence

Cholelithia

Decreasedosmotic

Pressure pushes

the diaphragm

Impaired ATP

production

DOB

Fluid volume excess r/t

compromised

regulatory mechanisms

as evidenced by

ascites, and dyspnea

Backflow of fluid to

the lungs

Backflow of fluids

to the heart

Increasedvenous

Jaundice

Ineffective breathing

pattern related to intra-

abdominal fluid collection

as manifested by

Impaired

Glycogen, lipid,

and protein

Early satiety

Pressure pushes

the stomach

Splenomegaly

Imbalanced nutrition: lessthan body requirements r/tinability to ingest nutrients(anorexia, early satiety) as

evidenced by lack ofappetite and intake.


8/12


XIII. Treatment/ManagementA. Drugs

NAME MECHANISM OF ACTION NURSING IMPLICATION

Generic: Spironolactone

Brand:Aldactone

Classification:Potassium SparingDiuretics

Dosage: 100 mg 1 tab

OD

Competitively blocks the action ofaldosterone in the distal tubule,

causing the loss ofsodium and water

retention of potassium

Alert: Monitor weight, blood pressure, and pulserate routinely with long-term use and duringrapid diuresis.

If oliguria or azotemia develops or increases,drug may need to be stopped.

Monitor fluid intake and output and electrolyte,BUN, and carbon dioxide levels frequently.

Monitor elderly patients, who are especiallysusceptible to excessive diuresis, because

circulatory collapse and thromboemboliccomplications are possible.

Advise patient to restrict intake of high-potassium foods and to avoid licorice and saltsubstitutes containing potassium.

Tell male patient drug may cause breastenlargement.

Advice patient to take drug with food to preventGI upset, and to take drug in morning toprevent need to urinate at night. If patientneeds second dose, tell him to take it in earlyafternoon, 6 to 8 hours after morning dose

Generic: Furosemide

Brand: Lasix

Classification: LoopDiuretics

Dosage: 20mg 1 TabBID

Inhibits sodium and chloridereabsorption at the proximal and

distal tubules and the ascendingloop of Henle

Decrease reabsorption ofsodium and chloride

Alert: Monitor weight, blood pressure, and pulserate routinely with long-term use and during

rapid diuresis. Use can lead to profound waterand electrolyte depletion.

If oliguria or azotemia develops or increases,drug may need to be stopped.

Monitor fluid intake and output and electrolyte,BUN, and carbon dioxide levels frequently.

Watch for signs of hypokalemia, such asmuscle weakness and cramps.

Consult prescriber and dietitian about a high-potassium diet or potassium supplements.Foods rich in potassium include citrus fruits,tomatoes, bananas, dates, and apricots.

Monitor elderly patients, who are especiallysusceptible to excessive diuresis, because

circulatory collapse and thromboemboliccomplications are possible.

Advice patient to take drug with food toprevent GI upset, and to take drug in morningto prevent need to urinate at night. If patientneeds second dose, tell him to take it in earlyafternoon, 6 to 8 hours after morning dose.

Instruct patient to stand slowly to preventdizziness and to strenuous exercise in hot

Risk for bleedingr/t increased

prothrombin time

Use of unsupported

vein, which are more

susceptible to traumaEasy fatigability

Hemorrhage orbleeding from the

veins to the

Decreased circulating

blood supply,

Decreased oncotic

pressure facilitates

fluid accumulation

at the lower lobes

Pneumonitis, both

lower lobes


9/12


weather to avoid worsening dizziness uponstanding quickly.

Advise patient to immediately report ringing inears, severe abdominal pain, or sore throat andfever; these symptoms may indicate toxicity.

Alert: Discourage patient from storing differenttypes of drugs in the same container,

increasing the risk of drug errors. The mostpopular strengths of this drug and digoxin arewhite tablets about equal in size.

Teach patient to avoid direct sunlight and touse protective clothing and a sunblock becauseof risk of photosensitivity reactions.

Generic: Enalapril

Brand: Vasotec

Classification:Angiotensin-ConvertingEnzyme Inhibitors

Dosage: 10mg 1 tab OD

Prevents ACE from convertingangiotensin I to angiotensin II, apowerful vasoconstrictor andstimulator of aldosterone release.This action leads to a decrease inblood pressure and in aldosteronesecretion, with a resultant slightincrease in serum potassium and

a loss of serum sodium fluid. Decrease in cardiac

workload

Decrease in peripheralresistance and bloodvolume

Encourage the patient to implement lifestylechanges, including weight loss, smokingcessation, decreased alcohol and salt in thediet, and increase exercise, to increase theeffectiveness of antihypertensive therapy.

Administer on an empty stomach, 1 hour beforeor 2 hours after meals, to ensure properabsorption of drug.

Monitor the patient carefully in any situation thatmight lead to a drop in fluid volume (e.g.,excessive sweating, vomiting, diarrhea,dehydration), to detect and treat excessivehypotension that may occur.

Provide comfort measures to help the patienttolerate drug effect. These include small,frequent meals; access to bathroom facilities;bowel program as needed; environmentalcontrols; safety precautions; and appropriateskin care as needed.

Provide thorough patient teaching, including thename of the drug, dosage prescribed,measures to avoid adverse effects, warning

signs of problems, and the need for periodicmonitoring and evaluation to enhance patientknowledge about drug therapy and to promotecompliance.

Offer support and encourage helping thepatient deal with the diagnosis and the drugregimen.

Generic Name:Clonidine

Brand Name: Catapres

Classification: Alpha-specific adrenergic

agonist

Dosage: 75mg 1 tab SLPRN for BP 150/90

Stimulates CNS alpha2-receptors

Decrease sympatheticoutflow

Do not discontinue drug abruptly becausesudden withdrawal can result in reboundhypertension, arrhythmias, flushing, and evenhypertensive encephalopathy and death.

Monitor blood pressure, pulse, rhythm andcardiac output regularly, even with ophthalmicpreparations in order to adjust dosage or

discontinue the drug if cardiovascular effectsare severe.

Arrange for supportive care and comfortmeasures, including rest and environmentalcontrol to decrease CNS irritant; headachemedication to relieve discomfort; safetymeasures if CNS effects occur to protect the

patient from injury; and protective measures ifCNS effects are severe.

Provide thorough patient teaching, includingdosage, potential adverse effects, safetymeasures, warning signs or problems, andproper administration for each route used, toenhance patient knowledge about drug therapyand to promote compliance.

Offer support and encouragement to help thepatient deal with the drug regimen.

Generic Name:Metronidazole

Brand Name: Flagyl

Classification:

Inhibits DNA synthesis insusceptible protozoa, leading toinability to reproduce andsubsequent cell death

Arrange for appropriate culture and sensitivitytests before beginning therapy to ensure properdrug for susceptible organisms. Treatment maybegin before test results are known.

Administer the complete course of the drug toget the full beneficial effects.

Monitor hepatic function before and periodically


10/12


Antiprotozoal

Dosage: 500mg 1 capevery 6 hours

during treatment to arrange to effectively stopthe drug if signs of failure or worsening liverfunction occur.

Provide comfort and safety measures if CNSeffects occur, such as side rails and assistancewith ambulation if dizziness and weakness arepresent, to prevent injury to the patient. Provide

oral hygiene and ready access to bathroomfacilities as needed to cope with GI effects.

Provide small, frequent, nutritious meals if GIupset is severe to ensure proper nutrition.Monitor nutritional status and arrange a dietaryconsultation as needed. Taking the drug withfood may also decrease GI upset.

Ensure that the patient is instructed about theappropriate dosage regimen to enhance patientknowledge about drug therapy and to promotecompliance.

Generic Name:Ampicillin-sulbactam

Brand Name: Unasyn

Classification: anti-infective

Dosage: 1.5g IV every 8hours

Inhibits bacterial cell-wallsynthesis during microbialmultiplication. Addition of

sulbactam enhances drugsresistance to beta-lactamase, anenzyme that can inactivateampicillin.

Ensure that the patient receives the full courseof the drug to increase effectiveness.

Explain storage requirements for suspensions

and the importance of completing theprescribed therapeutic course even if signs andsymptoms have disappeared, to increase theeffectiveness of the drug and decrease the riskof developing resistant strains.

Monitor the site of infection and presentingsigns and symptoms throughout the course ofdrug therapy. Failure of these signs andsymptoms to resolve may indicate the need tore-culture site.

Provide adequate fluids to replace fluid lost withdiarrhea.

Be sure to instruct the patient regarding theappropriate dosage regimen and possible

effects to enhance the patients knowledgeabout drug therapy and promote compliance.

The patient should try to drink a lot of fluids tomaintain nutrition (very important) even thoughnausea, vomiting, and diarrhea may occur.

Generic Name: HumanAlbumin

Brand Name:

Classification:

Dosage: 20% solution x2 OD for 5 days

increases intravascular oncoticpressure and causes movementof fluids from interstitial intointravascular space

Hypersensitivity or allergic reactions have beenobserved, and may in some cases progress tosevere anaphylaxis. Epinephrine should beavailable immediately to treat any acutehypersensitivity reaction.

Hypervolemia may occur if the dosage and rateof infusion are not adjusted to the patientsvolume status. At the first clinical signs ofpossible cardiovascular overload, e.g.,headache, dyspnea, increased blood pressure,

jugular venous distention, elevated centralvenous pressure, pulmonary edema, theinfusion should be stopped immediately and thepatient reevaluated.

Generic Name:predigested CHON

Brand Name:

Classification:

Dosage: Soft gel BID

Protein supplement

Generic Name: VitaminK

Brand Name:

Classification:Coagulant

Controls the clotting mechanismof the blood because its action isdirected at the precursor ofprothrombin. Prothrombin isactivated to form thrombin, anenzyme which, in turn, convertsfibrinogen to fibrin, the insolubleprotein that solidifies the bloodclot.

WOF possible symptoms of vitamin K toxicityinclude: thrombosis, vomiting, kidney tubuledegeneration.


11/12


Dosage: 100mg IV ODfor 3 doses

A. I.V. FluidsComponent of Fluids Classification of Fluids Effects or Uses Significance

PNSS

pH: 5.6 (4.5-7.0)

Calculated Osmolarity:310 mOsmol/liter

pH adjusted with

Hydrochloric Acid NFConcentration of

Electrolytes(mEq/liter): Sodium154 Chloride 154

Isotonic solution These intravenoussolutions are indicatedfor use in adults andchildren as sources ofelectrolytes and water

for hydration.

Indicated forpharmaceutics aid anddiluents for theinfusion of

compatibility drugadditives.

Capable ofinducingdiuresisdepending onthe clinical

condition ofthe patient.

B. SURGERIES:

None

XIV. Nursing Care Plans

A. Prioritization of Problems1. List of Problems

Fluid volume excess r/t compromised regulatory mechanisms as evidenced by abdominal edema,

weight gain, and dyspnea

Imbalanced nutrition: less than body requirements r/t inability to ingest nutrients (anorexia, early

satiety) as evidenced by lack of appetite and intake.

Fatigue/activity intolerance r/t altered body chemistry-changes in liver

function

Risk for bleeding r/t increased prothrombin time

Risk for impaired skin integrity r/t presence of edema or ascites

2. Basis of PrioritizationProblem Basis of Prioritization

1. Ineffective breathing pattern related to

intra-abdominal fluid collection as manifestedby abdominal distention

Aside from being the chief complaint of the

client, this was prioritized because oxygen is aneed for the body. If we follow the ABCs,Breathing is the second most importantpriority.

2. Fluid volume excess r/t compromisedregulatory mechanisms as evidenced byascites, and dyspnea.

According to Abraham Maslows hierarchy of needs,physiologic needs should be first attained/accomplished. In the physiologic needs exists yetanother hierarchy namely the OFFTERAS, which arealso arranged according to priority; oxygen, fluid,


12/12


food, temperature, elimination, rest, activity, andsex. Fluid Volume Excess falls under elimination.The patients normal functioning is impaired due tothe presenting situation resulting to disturbedhomeostasis like fluid shifting as evidenced byascites. And because of this problem, the problemsbelow developed and/or will further develop if

proper medical intervention wont come to place.3. Imbalanced nutrition: less than body

requirements r/t inability to ingest nutrients(anorexia, early satiety) as evidenced by lackof appetite and intake.

Nutrients are important because they are neededfor the repair of the damaged tissue. This isprioritized as the second problem because if theliver recovers, most of the problems would also bedealt with.

4. Risk for bleeding r/t increased prothrombintime.

In cirrhosis, the damaged liver cells regenerate asfibrotic areas instead of functional cells, causingalterations in liver structure, function, bloodcirculation and lymph damage which suggest thatbleeding might occur.

5. Risk for impaired skin integrity r/t presence

of ascites.

This is prioritized lastly because it is the least

important.

List of references:Tortora, Derickson (2006) Principles of Anatomy and Physiology 11th edition

Sheldon (1986) Boyds introduction to the study of disease 10th edition

NANDA

Kozier, Erb (2008) Fundamentals of Nursing 8th edition

Karch, (2007) Lippincotts Nursing Drug guide

Cirrhosis Case for Printing

Documents