LIVER

KELOMPOK 3:

1. DEDY KURNIAWAN S
2. EKO FEBRIANTORO

3. ELFINA MAHARANI

4. FATKHURROHMAN

5. FIRDA GARBO I

6. GALUH WIDYA K

7. KOMANG ASTRAWAN

8. NUR ARIS H

9. NURLAELY

10. NOVERITA G

TINGKAT II REGULER

KEMENTERIAN KESEHATAN REPUBLIK INDONESIA

POLTEKKES KEMENKES TANJUNG KARANG
JURUSAN KEPERAWATAN
2010
 LIVER

Assessment

Inspection:

1. Jaundice (the skin, the sclerae, and mucous membranes turn yellow)

Liver is unable to metabolice billirubun. The livers normal uptake of

billirubin from the blood impaired and alteraled conjugation and excretion
result in excessive circulating billirubin levels. Jaundice occurs when the
diseased liver does not remove enough bilirubin from the blood, causing
yellowing of the skin and whites of the eyes and darkening of the urine.
Bilirubin is the pigment that gives bile its reddish-yellow color.

2. Occuring on the nose, cheeks, the upper thorax and shoulder

3. Jugulare veins distended (JVD)

4. Spider angiomas

5. Caput medusae

6. Axillary and pubic hair changes

7. Ecchymosis

8. Dry skin

9. Purpuric lession

10. Dypsnea
Palpation

1. Hepatomegaly

Palpates the right upper quadrant for an enlarged liver below the costal (rib
cage) border. Hepatomegaly occurs in 60% of all cases of early cirrhosis.

2. The presence of inguinal or umbilical hernias, which are prone

to develop in clients with ascites because of increased intra abdominal
pressure.

With the client supine, the nurse brings the tape measure around the clients and
takes a measurement at the largest diameter of the abdoment. Before removing
the tape, the nurse marks the clients abdoment along the sides of the tape on
the clients flanks (sides) and midline to ensure that later measurements are
taken in a consistent manner. Abdominal girth measurements are done to
evaluate the progression of ascites.

3. Edema and ascites. When liver damage progresses to an

advanced stage, fluid collects in the legs, called edema, and in the abdomen,
called ascites. Ascites can lead to bacterial peritonitis, a serious infection.
4. Splenomegaly. When portal hypertension occurs, the spleen
frequently enlarges and holds white blood cells and platelets, reducing the
numbers of these cells in the blood. A low platelet count may be the first
evidence that a person has developed cirrhosis.
Percussion

The nurse may also elicit the presence of hepatomegaly by percussing for dullness over
the enlarged liver.