Care of Patients with Problems of the Biliary System and Pancreas Chapter 62 Care of Patients with Problems of the Biliary System and Pancreas Organs of the biliary system and the pancreatic ducts.

GI Tract Anatomic relationships of the large intestine.

Gallstones Gallstones within the gallbladder and obstructing the common bile and cystic ducts.

Acute vs. Chronic Cholecystitis Underlying cause Signs/symptoms Risk factors Role of diet

Gallstones

Cholecystectomy Laparoscopic vs. traditional Preoperative, intraoperative, postoperative similarities and differences

Traditional Cholecystectomy Standard preoperative care Operative procedure Postoperative care Opioids via PCA pump T-tube (and care of) Antiemetics Wound care NPO Nutrition therapy

Cancer of the Gallbladder Anorexia, weight loss, nausea, vomiting, general malaise, jaundice, hepatosplenomegaly; chronic, progressively severe epigastric or right upper quadrant pain Poor prognosis Surgery, radiation, chemotherapy

Acute Pancreatitis Laboratory and diagnostic tests Clinical manifestations Contributing factors Roles of collaborative health care team Priority of care Priority nursing interventions Patient and family teaching Resources

Acute Pancreatitis Acute pancreatitis. Axial CT image demonstrates peripancreatic stranding (arrow), a finding of pancreatitis. There are multiple gallstones in the gallbladder, which were the cause of this patient's pancreatitis.

Autodigestion The process of autodigestion in acute pancreatitis.

Complications of Acute Pancreatitis Hypovolemia Hemorrhage Acute kidney failure Paralytic ileus Hypovolemic or septic shock

Complications of Acute Pancreatitis Pleural effusion, respiratory distress syndrome, pneumonia Multisystem organ failure Disseminated intravascular coagulation Diabetes mellitus

Chronic Pancreatitis Progressive destructive disease of pancreas characterized by remissions and exacerbations Nonsurgical management: Drug therapy Analgesic administration Enzyme replacement Insulin therapy Nutrition therapy

Chronic Pancreatitis Chronic calcific pancreatitis. Axial unenhanced CT image demonstrates multiple pancreatic calcifications, which are a common finding in chronic pancreatitis. The pancreatic duct is also dilated, although that is generally better delineated on postcontrast images.

Pancreatic Abscess Most serious complication of pancreatitis; always fatal if untreated High fever Blood cultures Drainage via percutaneous method or laparoscopy Antibiotic treatment alone does not resolve abscess

Pancreatic Pseudocyst Complications: hemorrhage, infection, bowel obstruction, abscess, fistula formation, pancreatic ascites May spontaneously resolve Surgical intervention after 6 weeks

Pancreatic Carcinoma Nonsurgical management: Drug therapy Radiation therapy Biliary stent insertion

Pancreatic Cancer Carcinoma of the pancreas. A cross-section through the head of the pancreas and adjacent common bile duct showing both an ill-defined mass in the pancreatic substance (arrowheads) and the green discoloration of the duct resulting from total obstruction of bile flow.

Surgical Management Preoperative care: NG tube may be inserted TPN typically begun Operative procedure may include Whipple procedure

Surgical Management Postoperative care: Observe for complications GI drainage monitoring Positioning Fluid and electrolyte assessment Glucose monitoring

Whipple Procedure Whipple procedure, or radical pancreaticoduodenectomy. This surgical procedure involves resection of the proximal pancreas, adjoining duodenum, distal portion of the stomach, and distal portion of the common bile duct. The pancreatic duct, common bile ducts, and stomach are anastomosed to the jejunum.

Whipple Procedure The three anastomoses that constitute the Whipple procedure: choledochojejunostomy, pancreaticojejunostomy, and gastrojejunostomy.

Case Study A 68-year-old patient presents to the ED the day after Thanksgiving, stating that he has “eaten and drunk quite a bit.” He states that about 1 hour ago he experienced a sudden onset of pain in the left upper quadrant that radiates to his left flank. He rates the pain as an 8 on a 0-to-10 scale. The patient is admitted with acute pancreatitis. Which laboratory finding corroborates the diagnosis of acute pancreatitis? Serum lipase, 150 U/L Serum amylase, 200 U/L White blood cells, 6000 mcL Serum glucose, 80 mg/dL ANS: B A serum amylase of 200 U/L is elevated (normal range is approx. 23 to 85 U/L). Lipase normal range is 0-160 U/L, WBC normal range is 4800-10,800 ccm, and glucose normal range is 82-110 mg/dL. Amylase, lipase, WBC, and glucose are often higher than normal in patients with acute pancreatitis.

Case Study In preparing to care for the patient, which conditions does the nurse recognize as potential complications of acute pancreatitis? (Select all that apply.) Pancreatic infection Pleural effusion Diabetes mellitus Acute kidney failure Hemorrhage Pneumonia ANS: A, B, C, D, E, F All are potential complications of acute pancreatitis.

Case Study When the patient is asked about pain, he says that it is intense and continuous. He states that sometimes when he curls up in a fetal position the pain eases. Which intervention should be implemented for pain relief? PCA morphine sulfate PCA meperidine (Demerol) Oral hydromorphone (Dilaudid) IM fentanyl (Sublimaze) ANS: A Meperidine is not a good choice because it can cause seizures, especially in older adults. While hydromorphone is a good choice with acute pancreatitis pain, IV is the best route. Fentanyl is a good alternative, but the route chosen should be IV or transdermal. Another option is epidural analgesia.

Case Study The patient has been NPO but is now tolerating food. Which nutrition teaching point should the nurse be sure to include? Expect to experience nausea and vomiting as you begin to consume foods. Small and frequent meals are best. Low-carbohydrate, high-protein, and high-fat foods should be consumed. Use of alcohol and caffeine should be consumed in moderation. ANS: B Patients may experience nausea and vomiting but should not expect this to happen. High-carbohydrate, high-protein, and low-fat foods should be included in the diet. Alcohol and caffeine should be avoided.

Case Study The patient is being discharged to home. What instructions would the nurse tell the patient about when to call the provider? The patient should be instructed to notify the health care provider if acute abdominal pain occurs. Also, jaundice, clay-colored stools, or dark urine should be reported, because these are signs of biliary tract disease that may indicate complications as the disease progresses.

Audience Response System Questions Chapter 62 Audience Response System Questions 29

Question 1 A patient with chronic cholecystitis reports pruritus, clay-colored stools, and voiding dark, frothy urine. Which laboratory analysis is a priority in the nurse’s assessment of this patient? Liver function tests Total bilirubin Lipase level White blood cell count Answer: B Rationale: Excess circulating bilirubin present with chronic cholecystitis is responsible for pruritus and changes in stool and urine color. Cholecystitis is associated with several risks including hepatic disease, pancreatitis, and peritonitis. Monitoring liver function, pancreatic laboratory values, and white blood cell counts is also very important.

Question 2 Which patient is more likely to develop gallstones? 55-year-old African-American male with a history of diabetes mellitus 62-year-old Hispanic/Latino female with a history of irritable bowel syndrome 45-year-old Caucasian female with a family history of gallstones 60-year-old obese, American-Indian female with a history of diabetes mellitus Answer: D Rationale: Risk factors for developing gallstones include female gender, obesity, family history of gallstones, diabetes mellitus, American-Indian and Caucasian descent, rapid change in weight, and advanced age. More risk factors increase the likelihood of developing gallstones.

Question 3 In the care of a patient with acute pancreatitis, which assessment parameter requires immediate nursing intervention? Heart rate of 105 beats/min Blood pressure of 102/76 mm Hg Respiratory rate of 28 breaths/min Serum glucose of 136 mg/dL Answer: C Rationale: The patient with pancreatitis may develop pulmonary complications, pleural effusions, pulmonary infiltrates, and acute respiratory failure or ARDS. Increases in respiratory effort is an important assessment variable in the care of a patient with pancreatitis. Patients may also be hyperglycemic and hypovolemic. Assessing and treating endocrine function of the pancreas and perfusion variables are also important.