1. Chapter 50 Assessment and Management of Patients With Biliary Disorders

2. Review of Anatomy and Physiology
Gallbladder
Bile
Pancreas
Insulin
Glucagon
Somatostatin

3. Liver, Biliary System, and Pancreas

4. Question
Is the following statement true or false? Bile is stored in the gallbladder.

5. True Bile is stored in the gallbladder.
Answer
True Bile is stored in the gallbladder.

6. Cholelithiasis Pathophysiology
Pigment stones (formed from unconjugated pigments in the bile)
Cholesterol stones (Account for most cases of gallbladder disease)
Refer to Figure 50-2
Risk factors: refer to Chart 50-1

7. Clinical Manifestations of Cholelithiasis
None or minimal symptoms, acute or chronic
Pain
Biliary colic (Excruciating upper right abdominal pain that radiates to the back or right shoulder)
Jaundice
Changes in urine or stool color
Vitamin deficiency, fat soluble (vitamins A, D, E, and K)
Diagnostic tests: refer to Table 50-1

8. Cholesterol Gallstones and Pigment Gallstones

9. Question
Is the following statement true or false? Cholecystitis is when a patient has calculi in the gallbladder.

10. Answer
False Cholecystitis is inflammation of the gallbladder. Cholelithiasis is when a patient has calculi in the gallbladder.

11. Medical Management of Cholelithiasis
ERCP (Endoscopic Retrograde Cholangiopancreatography)
Dietary management
Medications: ursodeoxycholic acid and chenodeoxycholic acid
Laparoscopic cholecystectomy (“Lap chole”)
Nonsurgical removal
By instrumentation
Intracorporeal or extracorporeal lithotripsy (Stones are fragmented by laser)

12. Nonsurgical Removal of Gallstones

13. Laparoscopic Cholecystectomy

14. Nursing Process: The Care of the Patient With Cholelithiasis—Assessment
Patient history
Knowledge and education needs
Respiratory status and risk factors for respiratory complications postoperative
Nutritional status
Monitor for potential bleeding
GI symptoms: after laparoscopic surgery, assess for loss of appetite, vomiting, pain, distention, fever—potential infection or disruption of GI tract

15. Nursing Process: The Care of the Patient With Cholelithiasis—Diagnosis
Acute pain
Impaired gas exchange
Impaired skin integrity
Imbalanced nutrition
Deficient knowledge

16. Collaborative Problems and Potential Complications
Bleeding
GI symptoms
Complications related to surgery in general: atelectasis, thrombophlebitis

17. Nursing Process: The Care of the Patient With Cholelithiasis—Planning
Goals may include relief of pain, adequate ventilation, intact skin, improved biliary drainage
Optimal nutritional intake
Absence of complications
Understands self-care routines

18. Nursing Process: The Care of the Patient With Cholelithiasis—Interventions
Low Fowler’s position
NG or NPO until bowel sounds return; then a soft, low- fat, high-carbohydrate diet
Care of biliary drainage system
Analgesics, pain management
Turn, cough, and deep breathing; splinting to reduce pain
Ambulation
Self-care education: refer to Chart 50-2

19. Pancreatitis
Acute: pancreatic duct becomes obstructed, and enzymes back up, causing autodigestion and inflammation of the pancreas
Chronic: progressive inflammatory disorder with destruction of the pancreas; cells are replaced by fibrous tissue; pressure within the pancreas increases, obstructing the pancreatic and common bile ducts
Refer to Chart 50-3

20. Question What is a major symptom of chronic pancreatitis?
Recurrent attacks of severe upper abdominal and back pain accompanied by vomiting
Fever, jaundice, confusion, and agitation
Ecchymosis in the flank or umbilical area
Abdominal guarding

21. Answer
Recurrent attacks of severe upper abdominal and back pain accompanied by vomiting
Chronic pancreatitis has recurrent attacks of severe upper abdominal and back pain accompanied by vomiting. Acute pancreatitis presents with fever, jaundice, confusion, agitation, ecchymosis in the flank or umbilical area, and abdominal guarding.

22. Nursing Process: The Care of the Patient With Acute Pancreatitis—Diagnosis
Acute pain
Ineffective breathing pattern
Imbalanced nutrition
Impaired skin integrity
Refer to Chart 50-4

23. Collaborative Problems and Potential Complications
Fluid and electrolyte disturbances
Necrosis of the pancreas
Shock
Multiple organ dysfunction syndrome
DIC

24. Tumors of the Pancreas Pancreatic cysts Pancreatic cancer
Risk factors (Smoking, exposure to chemicals or toxins, diets high in fats or meats)
Sites of lesions (May develop in the head, body, or tail of pancreas)
Treatment may be palliative
Chemotherapy
Radiation (limited)
Surgery

25. Pancreatoduodenectomy (Whipple’s Procedure)

26. Multiple Sumps After Pancreatic Surgery