standard assessment of cirrhosis standard assessment of cirrhosis | allnurses

standard assessment of cirrhosis

by laddieo Jun 2, '08 | 18,858 Views | 1 Comments

  1. 0 Does anyone have any suggestions for me? I know all about cirrhosis, hepatitis... But for someone with these disorders/diseases, what would a standard assessment be.
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    #1 0
    Jun 2, '08 by Daytonite
    I'm not quite sure what you are meaning by a "standard assessment". To me a standard assessment is either a head to toe or body systems physical exam. However, I have a feeling that what you are meaning is what you want to specifically look for what is abnormal in the patient with cirrhosis or hepatitis, right?

    One of the nicest care plan books that I have that does this is
    Nursing Care Plans: Guidelines for Individualizing Client Care Across the Life Span, 7th edition, by Marilynn E. Doenges, Mary Frances Moorhouse and Alice C. Murr. Both conditions are listed in it. I will quote you what is in the book about assessment only for cirrhosis and hepatitis. I am not including the abnormal lab and test information because I am getting tired:

    "CIRRHOSIS (pages 453-454)
    Data depends on the underlying cause of the condition.
    ACTIVITY/REST
    May report: Weakness, fatigue, exhaustion
    May exhibit: Lethargy
    Decreased muscle mass/tone
    CIRCULATION
    May report: History of/recent onset of heart failure, pericarditis, rheumatic heart disease, or cancer (causing liver impairment leading to failure)
    Easy bruising, nosebleeds, bleeding gums
    May exhibit: Hypertension or hypertension (fluid shifts)
    Dysrhythmias, extra heart sounds (S3, S4)
    Jugular venous distension (JVD), distended abdominal veins, spider angiomas/collateral circulation
    Ecchymosis, petechiae
    anemia, leukopenia, thrombocytopenia, coagulation disorders, splenomegaly
    ELIMINATION
    May report: Flatulence
    Diarrhea or constipation; gradual abdominal enlargement
    May exhibit: Abdominal distension (hepatomegaly, splenomegaly, ascites)
    Decreased/absent bowel sounds
    Clay-colored stools, melena
    Hemorrhoidal varices
    Dark, concentrated urine; oliguria (hepatorenal syndrome/failure)
    FOOD/FLUID
    May report: Anorexia, food intolerance/indigestion
    Nausea/vomiting, hematemesis
    May exhibit: Weight loss or gain (fluid)
    Tissue wasting, delayed wound healing
    Edema generalized in tissues
    Dry skin, poor turgor
    Halitosis/fetor hepaticus. bleeding gums
    Hypoalbuminemia
    NEUROSENSORY
    May report: Significant other(s) may report personality changes, depressed mentation
    May exhibit: Changes in mentation, confusion, hallucinations, coma
    Slowed/slurred speech
    Asterixis (involuntary jerking movements of hands/tongue/feet associated with hepatic encephalopathy)
    PAIN/DISCOMFORT
    May report: Abdominal tenderness/RUQ pain
    Severe itching
    Pins/needles sensation, burning pain in extremities (peripheral neuropathy)
    May exhibit: Guarding/distraction behaviors
    Self-focus
    RESPIRATION
    May report: Dyspnea
    May exhibit: Tachypnea, shallow respiration, adventitious breath sounds
    Limited thoracic expansion (ascites)
    Hypoxia
    SAFETY
    May report: Itching/dryness of skin
    May exhibit: Fever (more common in alcoholic cirrhosis)
    Jaundiced skin and sclera, pruritis
    Spider angiomas, telangiectasis, palmar erythema
    Confusion progressing to delirium and coma (hepatic encephalopathy)
    Unsteady or shaky/jerking movements
    SEXUALITY
    May report: Menstrual disorders (women), impotence (men)
    May exhibit: Testicular atrophy, gynecomastia, loss of hair (chest, underarm, pubic)
    TEACHING/LEARNING
    May report: History of long-term alcohol or IV drug use/abuse, alcoholic liver disease. use of drugs affecting liver function
    History of biliary disease, hepatitis, exposure to toxins, liver trauma, complications of portal hypertension (e.g. episodes of bleeding esophageal varices and hepatorenal syndrome)"
    "HEPATITIS (pages 443-444)
    Data depends on the cause (type of hepatitis) and severity of liver involvement/damage.
    ACTIVITY/REST
    May report: Fatigue, weakness, general malaise, muscle aches
    CIRCULATION
    May exhibit: Bradycardia (severe hyperbilirubinemia)
    Jaundiced sclera, skin, mucous membranes
    ELIMINATION
    May report: Dark urine
    Diarrhea/constipation, clay-colored stools
    current/recent hemodialysis
    FOOD/FLUID
    May report: Loss of appetite (anorexia), weight loss or gain (edema)
    Nausea/vomiting
    May exhibit: Ascites
    NEUROSENSORY

    May exhibit: Irritability, drowsiness, lethargy, asterixis, headache
    PAIN/COMFORT
    May report: Abdominal cramping, right upper quadrant (RUQ) tenderness
    Myalgias, arthalgias; headache
    Itching (pruritis)
    May exhibit: Muscle guarding, restlessness
    RESPIRATION
    May report: Distaste for/aversion to cigarettes (smokers)
    Recent flu-like URI signs and symptoms
    SAFETY
    May report: Transfusion of blood/blood products in the past
    May exhibit: Fever
    Urticaria, maculopapular lesions, irregular patches of erythema
    Exacerbation of acne
    Spider angiomas, palmar erythema, gynecomastia in men (sometimes present in alcoholic hepatitis)
    Splenomegaly, posterior cervical node enlargement
    SEXUALITY
    May report: Lifestyle/behaviors increasing risk of exposure (e.g. sexual promiscuity, sexually active homosexual/bisexual male)
    TEACHING/LEARNING
    May report: History of known/possible exposure to virus, bacteria, or toxins (contaminated food, water, needles, surgical equipment or blood), carriers (symptomatic or asymptomatic), recent surgical procedure with halothane anesthesia, exposure to toxic chemicals (e.g. carbon tetrachloride, vinyl chloride)
    History of known/possible exposure to hepatotoxic prescription (e.g. sulfonamides, phenothiazides, isoniazid) or OTC drug use (e.g. acetaminophen)
    Use of herbal supplements associated with hepatotoxicity, (e.g. chaparral, JinBuHuan, germander, comfrey, mistletoe, skullcap, margosa oil, pennyroral)
    Use of street injection drugs or alcohol
    Travel to/immigration from China, Africa, Southeast Asia, Middle East (hepatitis B [HBV] and C [HBC] are endemic in these areas)
    Concurrent diabetes, heart failure, malignancy, or renal disease"

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