*SHIFTING DULLNESS: dullness will move to most dependent area (patient will turn side to side then supine to detect fluid movement)
*FLUID WAVE: ascites is present when tap causes a palpable fluid wave through the abdomen
A DISTENDED ABDOMEN, bulging flanks, and a protruding, displaced umbilicus are signs of ascites, free fluid in the peritoneal cavity. Cirrhosis, heart failure, renal failure, portal hypertension, chronic hepatitis, and cancer are common causes. Shifting dullness and a fluid wave indicate ascites.
* Provide privacy, explain the procedure to the patient, and perform hand hygiene.
* Place him supine and inspect his abdomen for distension. Observe for bulging flanks caused by ascites fluid sinking with gravity. (Gas-filled bowel loops rise to the surface.) Look for shiny, taut skin and prominent veins and assess
Include soft foods that are low in fiber, such as tender meats, cooked cereals, bread, pasta or milk. While many fruits and vegetables contain fiber, they are still important dietary components. Cooking fruits and vegetables, rather than eating them raw, will allow you to gain some of their vitamins and minerals while still eating soft foods.
your physician may recommend you limit your intake of fluids to avoid overloading the circulatory system.
Avoid alcohol if you have esophageal varies due to cirrhosis, as alcohol consumption can worsen this liver condition.
Many patients are placed on diets that regulate calories while maintaining adequate vitamin intake. A diet of foods that contains B vitamins as well as vitamin C is important for maintaining the structure of blood vessels, assisting with protein metabolism and helping with blood cell formation. Some foods that contain these vitamins include citrus fruits, dark green vegetables, liver, poultry, eggs, fish and legumes.
HISTORY. Determine if the patient has experienced personality changes such as agitation, forgetfulness, and disorientation. Inquire about fatigue, drowsiness, mild tremors, or flu-like symptoms. Ask about any past or present symptoms that may indicate cirrhosis, such as changes in bowel habits or menstrual irregularities. Elicit a history of easy bruising, nosebleeds, or bleeding gums. Determine the patient's drinking patterns and how long they have existed. Determine if the patient has had early-morning nausea and vomiting, anorexia, indigestion, weight loss, weakness, lethargy, epigastric discomfort, or altered bowel habits. Ask about any recent sexual dysfunction.
PHYSICAL EXAM. Inspect for signs of muscle atrophy. Note whether the patient's abdomen is protruding. Assess the patient's skin, sclera, and mucous membranes, observing for poor skin turgor, signs of jaundice, bruising, spider angiomas, and palmar erythema (reddened palms). Observe the patient's trunk, and note the presence of gynecomastia (enlarged breasts). Observe the abdomen for distention, an everted umbilicus, and caput medusae (a plexus of dilated veins about the umbilicus); measure the abdominal girth.
When assessing the patient's upper extremities, test for asterixis (liver flap or flapping tremor). Have the patient stretch out her or his arm and hyperextend the wrist with the fingers separated, relaxed, and extended. The patient in stages II (impending) and III (stuporous) of hepatic encephalopathy may have a rapid, irregular flexion and extension (flapping) of the wrist. Note any tenderness or discomfort in the patient's abdomen. Palpate for hepatomegaly by gently rolling the fingers under the right costal margin. The liver is normally soft and usually can be felt under the costal margin. Percuss the patient's abdomen. Note a shifting dullness in the abdomen if ascites is present. Auscultate the abdomen and assess for hypoactive, hyperactive, or normal bowel sounds.
PSYCHOSOCIAL. Cirrhosis is a chronic disease that dictates lifestyle changes for the patient and significant others. Determine the patient's response to the diagnosis and his or her ability to cope with change. Identify the patient's past ability to cope with stressors, and determine if these mechanisms were successful.
HISTORY. Cholecystitis often begins as a mild intolerance to fatty food. The patient experiences discomfort after a meal, sometimes with nausea and vomiting, flatulence, and an elevated temperature. Over a period of several months or even years, symptoms progressively become more severe. Ask the patient about the pattern of attacks; some mistake severe gallbladder attacks for a heart attack until they recall similar, less severe episodes that have preceded it. An acute attack of cholecystitis is often associated with gallstones, or cholelithiasis. The classic symptom is pain in the right upper quadrant that may radiate to the right scapula, called biliary colic. Onset is usually sudden, with the duration from less than 1 to more than 6 hours. If the flow of bile has become obstructed, the patient may pass clay-colored stools and dark urine.
PHYSICAL EXAM. The patient with an acute gallbladder attack appears acutely ill, is in a great deal of discomfort, and sometimes is jaundiced. A low-grade fever is often present, especially if the disease is chronic and the walls of the gallbladder have become infected. Right upper quadrant pain is intense in acute attacks and requires no physical examination. It is often followed by residual aching or soreness for up to 24 hours. A positive Murphy's sign, which is positive palpation of a distended gallbladder during inhalation, may confirm a diagnosis.
PSYCHOSOCIAL. The patient with an acute attack of cholelithiasis may be in extreme pain and very upset. The experience may be complicated by guilt if the patient has been advised by the physician in the past to cut down on fatty foods and lose weight. The attack may also be very frightening if it is confused with a heart attack.