Assessment

HISTORY. Take a detailed medication history with particular attention to hepatotoxic medications, such as anesthesia agents, analgesics, antiseizure medications, cocaine, alcohol, isoniazid (INH), and oral contraceptives. Ask about any recent travel to China, southeast Asia, sub-Saharan Africa, the Pacific Islands, and areas around the Amazon River, which may have exposed the patient to hepatitis B. Explore the patient's occupational history for hepatitis exposure; patients who are daycare workers, dental workers, physicians, nurses, or hospital laboratory workers are particularly at risk. Ask the patient if she or he has experienced previous liver or biliary disease. Intravenous (IV) drug users and male homosexuals are at risk for hepatitis and, therefore, liver failure. Those who eat raw shellfish are at similar risk.

Early symptoms include personality changes (agitation, forgetfulness, disorientation), fatigue, anorexia, drowsiness, and mild tremors. Some patients experience sleep disturbance and low-grade fevers. As larger areas of the liver are destroyed, the patient has increasing fatigue, confusion, and lethargy. If the patient has long-standing liver failure, he or she experiences jaundice, dry skin, early-morning nausea, vomiting, anorexia, weight loss, altered bowel habits, and epigastric

574 Liver Failure discomfort. If sudden FHF occurs, the patient may develop encephalopathy (decreased mental status, fixed facial expression), peripheral swelling, ascites, and bleeding tendencies. Urine is often dark from bilirubin, and stools are often light-colored because of the absence of bilirubin.

PHYSICAL EXAMINATION. The patient with acute liver failure usually has jaundiced skin and sclera. Fluid retention results in ascites and peripheral edema. The patient's facial expression appears fixed, her or his movements are hesitant, and speech is slow. Usually, the patient's mental status is markedly decreased, and you may smell fetor hepaticus, a sweet fecal odor, on the patient's breath. The patient may have multiple bruises, a bloody nose, or bleeding gums.

The patient's peripheral pulses are bounding and rapid, indicating fluid overload and a hyper-dynamic circulation. You may also palpate peripheral edema, an enlarged firm liver in acute failure and a small hard liver in chronic failure, an enlarged spleen, a distended abdomen, and an abdomen with shifting dullness to percussion and a positive fluid wave because of ascites. As ascites worsens, the patient develops hernias, an everted umbilicus, and an elevated and displaced heart because of a raised diaphragm. Usually, the patient with late disease has neck vein distension, and men develop gynecomastia (enlarged breasts), testicular atrophy, and scant body hair. When you monitor the patient's vital signs, you may find an elevated temperature and a low-to-normal blood pressure; if the physician initiates hemodynamic monitoring, the cardiac output may be low if ascites is decreasing the right ventricular filling pressure and if the systemic vascular resistance is low.

PSYCHOSOCIAL. The patient may feel upset or guilty if he or she contracted the disease while traveling. Use a nonjudgmental approach to elicit the patient's feelings if the condition is related to alcohol abuse. If the patient is a candidate for a liver transplant, determine the patient's emotional stability, ability to cope with a complex medical regimen, and ability to rely on significant others.

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