LIVER The liver is located in the upper right-hand portion of the abdominal cavity, beneath the diaphragm and

on top of the stomach, right kidney, and intestines. The liver, a dark reddish-brown organ that weighs about 3 pounds, has multiple functions. There are two distinct sources that supply blood to the liver: oxygenated blood flows in from the hepatic artery and nutrient-rich blood flows in from the hepatic portal vein. The liver consists of two main lobes, both of which are made up of thousands of lobules. These lobules are connected to small ducts that connect with larger ducts to ultimately form the hepatic duct. The hepatic duct transports bile produced by the liver cells to the gallbladder and duodenum (the first part of the small intestine). The liver regulates most chemical levels in the blood and excretes a product called bile, which helps to break down fats, preparing them for further digestion and absorption. All of the blood leaving the stomach and intestines passes through the liver. The liver processes this blood and breaks down the nutrients and drugs in the blood into forms that are easier to use for the rest of the body. Some of the more well-known functions include: production of bile, which helps carry away waste and break down fats in the small intestine during digestion, production of certain proteins for blood plasma, production of cholesterol and special proteins to help carry fats through the body, conversion of excess glucose into glycogen for storage (This glycogen can later be converted back to glucose for energy.), regulation of blood levels of amino acids, which form the building blocks of proteins, processing of hemoglobin for use of its iron content (The liver stores iron.), conversion of poisonous ammonia to urea (Urea is one of the end products of protein metabolism that is excreted in the urine.), clearing the blood of drugs and other poisonous substances, regulating blood clotting, resisting infections by producing immune factors and removing bacteria from the blood stream. When the liver has broken down harmful substances, they are excreted into the bile or blood. Bile by-products enter the intestine and ultimately leave the body in the feces. Blood byproducts are filtered out by the kidneys and leave the body in the form of urine.

Femur The femur, also known as the thigh bone, is the longest bone of the human skeleton located in between the hip bone and the knee. This bone is one of the strongest bones in the human skeleton and functions in supporting the weight of the body and allowing motion of the lower extremity. A femur bone is found in each leg. The bones of the hip are the femur (the thighbone) and the pelvis. The top end of the femur is shaped like a ball. This ball is called the femoral head. The femoral head fits into a round socket on the side of the pelvis. This socket is called the acetabulum. The femoral head is attached to the rest of the femur by a short section of bone called the femoral neck. A large bump juts outward from the top of the femur, next to the femoral neck. This bump, called the greater trochanter, can be felt along the side of your hip. Large and important muscles connect to the greater trochanter. One muscle is the gluteus medius. It is a key muscle for keeping the pelvis level as you walk. Articular cartilage is the material that covers the ends of the bones of any joint. Articular cartilage is about one-quarter of an inch thick in the large, weight-bearing joints like the hip. Articular cartilage is white and shiny and has a rubbery consistency. It is slippery, which allows the joint surfaces to slide against one another without causing any damage. The function of articular cartilage is to absorb shock and provide an extremely smooth surface to make motion easier. Articular cartilage is essential everywhere that two bony surfaces move against one another, or articulate. In the hip, articular cartilage covers the end of the femur and the socket portion of the acetabulum in the pelvis. The cartilage is especially thick in the back part of the socket, as this is where most of the force occurs during walking and running. The acetabulum is chiefly spherical in its superior margin and allows for approximately 170 of coverage of the femoral head. The femoral head is not perfectly spherical, and joint congruity is precise only in the weight-bearing position. The internal trabecular system of the femoral head is oriented along lines of stress. Thick trabeculae that arise from the calcar extend into the weight-bearing dome of the femoral head and help resist to compressive loads across the joint. The arterial supply to the femoral head is principally provided by 3 sources: (1) an extracapsular arterial ring at the base of the femoral neck, (2) ascending branches of the arterial ring on the femoral neck surface, and (3) arteries of the round ligament. This arterial supply is well affixed to the femoral neck and is easily damaged with any femoral neck fracture displacement. Furthermore, nutrient vessels to the femoral head terminate in small arterioles that are easily occluded with small embolic matter

The posterior-superior retinacular arteries provide the major blood supply to the epiphysis. They traverse the femoral neck and are contained within the joint capsule and give rise to the lateral epiphyseal vessels at the junction of the femoral head and neck. From there, they penetrate the femur and supply the femoral epiphysis.

Avascular Necrosis Avascular necrosis (AVN) of the femoral head is a pathologic process that results from interruption of blood supply to the bone. Although patients are initially asymptomatic, avascular necrosis (AVN) of the femoral head usually progresses to joint destruction, requiring total hip replacement. The femoral head is the most vulnerable site for the development of avascular necrosis (AVN). The site of necrosis is usually immediately below the weightbearing articular surface of the bone (ie, the anterolateral aspect of the femoral head). This is the site of greatest mechanical stress. Avascular necrosis is the death of bone tissue due to a lack of blood supply. Also called osteonecrosis, avascular necrosis can lead to tiny breaks in the bone and the bone's eventual collapse. The blood flow to a section of bone can be interrupted if the bone is fractured or the joint becomes dislocated. Avascular necrosis is also associated with long-term use of high-dose steroid medications and excessive alcohol intake. The most common joint affected by avascular necrosis is the hip. Avascular necrosis worsens with time, so managing it is a lifelong process. Avascular necrosis may result from different factors: Vascular occlusion is characterized by the interruption of the extraosseous blood supply via factors such as direct trauma nontraumatic stress, and stress fracture. In altered lipid metabolism, animal studies have led to the hypothesis that increased levels of serum lipids leads to lipid deposition in the femoral head, causing femoral hypertension and ischemia. Lipid-levellowering drugs in animals reverse this process. Corticosteroid administration was associated with fat emboli in the femoral heads of rabbits. Disorders of the coagulation system have been implicated in the pathogenesis of AVN. Typically, it is a secondary event triggered by a familial thrombophilia, hypercholesterolemia, allograft organ rejection, other disorders , or pregnancy. In healing process a necrotic bone triggers a process of repair that includes osteoclasts, osteoblasts, histiocytes, and vascular elements. Osteoblasts build new bone on top of the dead bone, leading to a thick scar that prevents revascularization of the necrotic bone, with resultant abnormal joint remodeling and joint dysfunction causing pain to the client. Uneven gait as well as limited range of movement may result due to the pain that the client feels. In Primary cell death, osteocyte death without other features of AVN has been seen in renal transplant patients, as well as in patients receiving steroids and those who consume significant amounts of alcohol.

In Mechanical stress, animal studies have shown an association between increased weight bearing and an increased incidence of AVN of the femoral head. Correlating this to the condition of the client, since he had a trauma last 5 years this may have caused a vascular damage leading to a decreased blood supply and bone ischemia which may eventually lead to bone necrosis. Bone and surrounding joint may collapse causing pain to the client. The pain may be severe enough to limit a person's range of motion in the affected joint. Uneven gait may also result because of pain.

Liver Cirrhosis Cirrhosis is a slowly progressing disease in which healthy liver tissue is replaced with scar tissue, eventually preventing the liver from functioning properly. The scar tissue blocks the flow of blood through the liver and slows the processing of nutrients, hormones, drugs, and naturally produced toxins. It also slows the production of proteins and other substances made by the liver. This is called liver failure, sometimes referred to as end-stage liver disease. Cirrhosis can be caused by a number of conditions, including long-standing inflammation, poisons, infections, and heart disease, as well as chronic alcoholism and chronic hepatitis, the most common causes. Alcohol can poison all living cells, causing liver cells to become inflamed and die. The death of liver cells leads your body to form scar tissue around veins of your liver. Healing liver cells form nodules, which also press on the liver veins. Bile is a substance produced by the liver to help the body digest fats. Bile is a substance produced by the liver to help the body digest fats. Yellowing of the skin and eyes may result from the deposition of bilirubin in the tissues. Bilirubin is a product of the breakdown of old blood cells in the liver. Loss of liver function affects the body in many ways. Cirrhosis, if severe enough, can cause many different complications such as portal hypertension, hepatic encephalopathy, bleeding varices, infection and ascites. The nodules and scar tissue can compress veins within the liver. This causes the blood pressure within the liver to be high, a condition known as portal hypertension. Portal hypertension may cause bleeding into the intestines and fluid accumulation throughout the body. In Hepatic encephalopathy, toxins build up in the bloodstream because the scarred liver is unable to rid them from the body. The toxins can cause someone to behave bizarrely, to become confused, and to lose their ability to take care of themselves or others. Some people become very sleepy and cannot waken easily. Portal hypertension causes backing up of blood flow in the veins of the stomach and esophagus. This causes the veins to enlarge, forming "varices".These varices can tear and bleed, and this bleeding can be life threatening. If you have cirrhosis, you are at risk for many infections because your liver cannot form the proteins needed to fight off infection. High pressures (portal hypertension) force fluid out of blood vessels in your liver, pooling it in your abdomen. Correlating this to the condition of the client, since he is a chronic alcohol drinker a liver fibrosis may have developed which may cause to a decrease in liver functions. The client has icteresia or yellowing of the eyes. This is an indicator that there is a decreased in bilirubin conjugation. Liver fibrosis may also caused portal hypertension which in turn can also cause

bleeding varices which is noted on the client. Since one of the functions of the liver is protein synthesis, a damaged to it will cause a decreased in protein synthesis. Prolonged PT, PTT may be result because protein is one of the essential components for anticoagulant production.

Liver Cirrhosis

Signs and symptoms from the Textbook

Signs and symptoms manifested by the client

Rationale

Yellowing of the skin +

Decreased bilirubin conjugation may lead to increase serum bilirubin.

Yellowing of the eyes -

Decreased bilirubin conjugation may lead to increase serum bilirubin.

behave bizarrely, confused, lose their ability to take care of themselves

Due to increase ammonia in the brain. -

Ascites

High pressures (portal hypertension) force fluid out of blood vessels in your liver, pooling it in the abdomen

Avascular Necrosis Signs and symptoms from the Textbook Signs and symptoms manifested by the client Rationale

Pain +

Due to bone and joint collapse

Limited Range of Movement +

Pain may limit the clients range of motion

Uneven gait +

Discomfort and pain felt by the during ambulation may result to uneven gait