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

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

3. Gallstones (cont’d)

4. Acute vs. Chronic Cholecystitis
Need to treat the underlying cause
What are the:
signs/symptoms? Pg 1317
Risk factors?
How does the diet play into this?
Highest Risk: Four F’s
Female
Forty
Fat
Fertile

5. Acute vs Chronic Cholelithiasis
2 types:
Calculous
Gallstones cause irritation or blockage of ducts
Acalculous
Inflammation associated with biliary stasis
May rupture leading to peritonitis
Repeated episodes of cystic duct obstruction
Gallbladder becomes fibrotic and contracted
Can lead to pancreatitis or cholangitis
Jaundice is often a symptom as well as icterus

6. Cholecystectomy 2 procedures: How do you provide nursing care?
Laparoscopic vs. traditional
How do you provide nursing care?
Preoperative
intraoperative
postoperative similarities and differences

7. Cancer of the Gallbladder
Rare! Most common:
Adenocarcinoma
Squamous cell
Symptoms include:
Anorexia, weight loss, nausea, vomiting, general malaise, jaundice, hepatosplenomegaly; chronic, progressively severe epigastric or right upper quadrant pain
Poor prognosis
Treatment:
Surgery, radiation, chemotherapy

8. Acute vs Chronic Pancreatitis
Chronic:

9. Acute Pancreatitis Serious inflammatory process! What: (group work!)
Caused by: premature activation of excessive pancreatic enzymes that autodigest cells and cause fibrosis(Students review pg 1321, fig 62-2 on own)
What: (group work!)
Laboratory and diagnostic tests are performed? (pg 1323)
Are the clinical manifestations?
Are the contributing factors?
Roles of collaborative health care team?
Is the priority of care & nursing interventions?
Patient and family teaching should you do?

10. Complications of Acute Pancreatitis
Hypovolemia
Hemorrhage
Acute kidney failure
Paralytic ileus
Hypovolemic or septic shock
Pleural effusion, respiratory distress syndrome, pneumonia
Multisystem organ failure
Disseminated intravascular coagulation
Diabetes mellitus

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

12. 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

13. Pancreatic Carcinoma Leading cause of cancer deaths in the US.
Difficult to diagnose early due to its location
Limited treatment results
Low 5 year rate of survival
Nonsurgical management:
Drug therapy
Radiation therapy
Biliary stent insertion

14. Surgical Management Preoperative care:
NG tube may be inserted
TPN typically begun
Operative procedure may include Whipple procedure (see next slide)
Postoperative care:
Observe for complications
GI drainage monitoring
Positioning
Fluid and electrolyte assessment
Glucose monitoring

15. 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, 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.

16. NCLEX Review Questions
Chapter 62
NCLEX Review Questions 16

17. 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.

18. Answer
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.

19. 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.

20. Answer
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.

21. 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.

22. Answer
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.