Liver
"CIRRHOSIS
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
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