Medical-Surgical Nursing: Concepts & Practice 3rd edition Chapter 30 Care of Patients with Disorders of the Liver, Gallbladder, and Pancreas Copyright © 2017, Elsevier Inc. All rights reserved.

Cholelithiasis and Cholecystitis Etiology Ethnic predisposition to gallstones Pathophysiology Signs and symptoms None to severe and unbearable pain Chronic cholecystitis is biliary colic

Risk factors Female High-fat diet Obesity Age and genetic predisposition Type 2 diabetes rapid weight loss (increases cholesterol)

Gallstones See Figure 30-1 on p. 695.

Cholelithiasis and Cholecystitis Diagnosis Ultrasonography Computed tomography (CT) Endoscopic retrograde cholangiopancreatography (ERCP) Cholescintigraphy (hepatoiminodiacetic acid [HIDA] scan) Liver function tests

Comparison of Symptoms of Gallbladder Disorders Pain or biliary colic Nausea, vomiting Indigestion and flatulence Low-grade fever Jaundice See Table 30-1 on p. 695.

Cholelithiasis and Cholecystitis Treatment Diet Correction of bile obstruction Antibiotics Post-cholecystectomy diet Surgery Complications

Postoperative Laparoscopic Cholecystectomy Remove the bandages from the puncture sites the day after surgery and shower. Report the following signs and symptoms if they occur: redness, swelling, bile-colored drainage or pus from any surgical site, severe abdominal pain, nausea, vomiting, chills, or fever, light-colored stool, dark urine, or yellow tint to the eyes or skin because these signs may indicate obstruction of the flow of bile.

Postoperative Laparoscopic Cholecystectomy (Cont.) Normal activities may be resumed gradually. Return to work is probable at 1 week postsurgery. Stick to a low-fat diet for several weeks; slowly introduce fattier foods to determine if these cause unpleasant symptoms.

Nursing Management Preoperative care Postoperative care Caring for a T-tube

T-Tube See Figure 30-2 on p. 697.

Hepatitis Etiology and pathophysiology Signs and symptoms Types of viral hepatitis HBV among Asian Americans Signs and symptoms Pre-icteric phase Icteric phase Posticteric phase Complications

Comparison of Hepatitis-Causing Viruses Transmission modes Incubation periods Infective periods Signs and symptoms See Table 30-2 on p. 698.

Diagnosis of Hepatitis Serologic assays or enzyme immunoassays (EIAs) Liver biopsy Elevations in liver function tests (LFTs)

Laboratory Tests Aspartate aminotransferase (AST) Alanine aminotransferase (ALT) Gamma-glutamyl transpeptidase (GGT) Bilirubin Alkaline phosphatase Serum albumin Serum bilirubin (total) Prothrombin time See Table 30-3 on p. 700.

Treatment of Hepatitis There is no specific treatment for acute viral hepatitis. Nondrug measures include a well-balanced diet and rest and avoiding hepatotoxic substances, including alcohol and certain medications. Active and passive immunity Antiviral therapy

Expected Outcomes Patient will maintain body weight within normal limits during illness. Patient will verbalize lessened fatigue after rest periods each day. Patient will verbalize a decrease in pain after institution of nursing measures to decrease discomforts.

Expected Outcomes (Cont.) Patient will verbalize knowledge of disease process and self-care within 2 days. Patient will engage in appropriate diversional activities during convalescence.

Nursing Interventions Monitor progress. Prevent the spread of infection. Patient and family teaching—proper handling of body secretions, proper hand hygiene, and limiting contact Psychological support Ensure adequate nutrition

Prevention of Hepatitis Home considerations for different types of viral hepatitis Standard Precautions guidelines Infection control

Cirrhosis Etiology Postnecrotic cirrhosis Laënnec’s cirrhosis or portal cirrhosis Biliary cirrhosis Cardiac cirrhosis Liver-related deaths

Cirrhosis (Cont.) Diagnosis Liver biopsy Liver function studies CT and liver scan Magnetic resonance cholangiopancreatography Treatment—stopping the liver damage and restoring the liver’s functions

Signs and Symptoms Subjective symptoms Fatigue Weakness Headache Anorexia Indigestion Abdominal pain Nausea Vomiting

Signs and Symptoms (Cont.) Fluid retention in the right hemithorax or ascites can limit expansion of the chest and cause dyspnea. Objective symptoms of liver cirrhosis include excessive gas, skin rashes, itching, and fever. Leg and foot edema and palmar erythema Caput medusa Bleeding and bruising

Signs and Symptoms (Cont.) Deficiencies in vitamin K, thrombin, or prothrombin interfere with clot formation. The liver often is enlarged and “knobby” and is palpable below the level of the right rib cage. Abdominal distention The spleen also enlarges.

Signs and Symptoms (Cont.) Peripheral edema and ascites Skin lesions, jaundice, pruritus, bleeding disorders, endocrine disorders, and peripheral neuropathy occur in late disease. Spider angiomas may appear on the face, neck, upper trunk, and arms. The angiomas may blanch with pressure.

Signs and Symptoms of Cirrhosis See Figure 30-3 on p. 707. From Lewis SL, Heitkemper MM, Dirksen SR, et al: Medical-surgical nursing: assessment and management of clinical problems, ed. 9, St. Louis, 2014, Mosby.

Relationship of Systemic Portal Hypertension and Ascites in Cirrhosis See Concept Map 30-1 on p. 706.

Nursing Management of Cirrhosis Assessment Assess for safety issues Laboratory tests Alcohol withdrawal Nursing diagnosis Planning and implementation Evaluation

Complications of Cirrhosis Esophageal varices Encephalopathy Delirium, convulsions, asterixis, and coma Fetor hepaticus

Treatment for Esophageal Varices See Figure 30-4 on p. 711.

Liver Transplantation Legal and ethical considerations Nursing management Care of drains Immunosuppressants Liver function monitoring

Cancer of the Liver Etiology Pathophysiology Signs and symptoms Diagnosis Treatment Nursing management

Acute Pancreatitis Etiology Pathophysiology Signs and symptoms Diagnosis Treatment Nursing management

Chronic Pancreatitis Etiology and pathophysiology Signs and symptoms Diagnosis Determination of bicarbonate concentration and output in the duodenum after stimulation with secretin is the definitive test for chronic pancreatitis.

Chronic Pancreatitis (Cont.) Treatment Nursing management Pain management Complications, including diabetes mellitus Avoid alcohol.

Pathophysiology of Acute Pancreatitis See Concept Map 30-2 on p. 713.

Cancer of the Pancreas Etiology Pathophysiology Pancreatic cancer deaths Healthy gums for better pancreatic health Pathophysiology Cigarette smoking Adenocarcinoma Tumor in the head of the pancreas Tumor in the body and tail of pancreas

Cancer of the Pancreas (Cont.) Signs and symptoms Deep vein thrombosis Diagnosis Ultrasonography, imaging techniques, and fine-needle biopsy Elevated carcinoembryonic antigen levels Serum beta-human chorionic gonadotropin and carbohydrate antigen (CA) 72-4 Tumor markers CA 19-9 and CA 242

Cancer of the Pancreas (Cont.) Treatment Keep the patient comfortable. Treat or prevent malnutrition. Surgical treatment, including Whipple procedure, or radical pancreaticoduodenectomy Other treatments Nursing management Community care