standard assessment of cirrhosis

Daytonite, BSN, RN · Jun 3, 2008

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"