Assessment of Patients With Hepatic Disorders

Assessment

HEALTH HISTORY

If liver function test results are abnormal, the patient may need to be evaluated for liver disease. In such cases, the health history will focus on exposure of the patient to hepatotoxic substances or in-fectious agents. The patient’s occupational, recreational, and travel history may assist in identifying exposure to hepatotoxins (eg, in-dustrial chemicals, other toxins) responsible for illness. The pa-tient’s history of alcohol and drug use, including but not limited to the use of injectable drugs, provides additional information about exposure to toxins and infectious agents. Many medications (including acetaminophen, ketoconazole, and valproic acid) are responsible for hepatic dysfunction and disease. A careful med-ication history to assess hepatic dysfunction should address all pre-scribed and over-the counter medications, herbal remedies, and dietary supplements used by the patient currently and in the past.

Lifestyle behaviors that increase the risk for exposure to infec-tious agents are identified. Injectable drug use, sexual practices, and a history of foreign travel are all potential risk factors for liver disease. The amount and type of alcohol consumption are iden-tified using screening tools (questionnaires) that have been de-veloped for this purpose.

The history also includes an evaluation of the patient’s past medical history to identify risk factors for the development of liver disease. Current and past medical conditions, including those of a psychological or psychiatric nature, are identified. The family history includes questions about familial liver disorders that may have their etiology in alcohol abuse or gallstone disease, as well as other familial or genetic diseases, such as hemochro-matosis, Wilson’s disease, or alpha-1 antitrypsin disease.

The history also includes reviewing symptoms that suggest liver disease. Symptoms that may have their etiology in liver disease but are not specific to hepatic dysfunction include jaundice, malaise, weakness, fatigue, pruritus, abdominal pain, fever, anorexia,weight gain, edema, increasing abdominal girth, hematemesis, melena, hematochezia (passage of bloody stools), easy bruising, decreased libido in men and secondary amenorrhea in women, changes in mental acuity, personality changes, and sleep distur-bances.

PHYSICAL EXAMINATION

The nurse assesses the patient for physical signs that may occur with liver dysfunction, including pallor of chronic illness and jaundice. The skin, mucosa, and sclerae are inspected for jaun-dice, and the extremities are assessed for muscle atrophy, edema, and skin excoriation secondary to scratching. The nurse observes the skin for petechiae or ecchymotic areas (bruises), spider an-giomas, and palmar erythema. The male patient is assessed for unilateral or bilateral gynecomastia and testicular atrophy due to endocrine changes. The patient’s cognitive status (recall, mem-ory, abstract thinking) and neurologic status are assessed. The nurse observes for general tremor, asterixis, weakness, and slurred speech. These symptoms are discussed later.

The nurse assesses the abdomen for dilated abdominal wall veins, ascites, and a fluid wave (discussed later). The abdomen is palpated to assess liver size and to detect any tenderness over the liver. The liver may be palpable in the right upper quadrant. A palpable liver presents as a firm, sharp ridge with a smooth sur-face (Fig. 39-3). The nurse estimates liver size by percussing its upper and lower borders. When the liver is not palpable but ten-derness is suspected, tapping the lower right thorax briskly may elicit tenderness. For comparison, the nurse then performs a sim-ilar maneuver on the left lower thorax.

If the liver is palpable, the examiner notes and records its size and consistency, whether it is tender, and whether its outline is regular or irregular. If the liver is enlarged, the degree to which it descends below the right costal margin is recorded to provide some indication of its size. The examiner determines whether the liver’s edge is sharp and smooth or blunt, and whether the en-larged liver is nodular or smooth. The liver of a patient with cirrhosis is small and hard, whereas the liver of a patient with acute hepatitis is soft, and the hand easily moves the edge.

Tenderness of the liver implies recent acute enlargement with consequent stretching of the liver capsule. The absence of ten-derness may imply that the enlargement is of long-standing du-ration. The liver of a patient with viral hepatitis is tender, whereas that of a patient with alcoholic hepatitis is not. Enlargement of the liver is an abnormal finding requiring evaluation.