Chapter 6 Care of the Patient with a

Chapter 6 Care of the Patient with a
Gallbladder, Liver, Biliary Tract, or Exocrine Pancreatic Disorder The exocrine organs of digestion are those whose functions aid the body in digesting nutrients. Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Laboratory and Diagnostic Examinations
Serum bilirubin test Liver enzyme tests Serum protein test Oral cholecystography (gallbladder series) Intravenous cholangiography (IV cholangiogram) Operative cholangiography T-tube cholangiogram Ultrasound of the liver, gallbladder, and biliary system Gallbladder scanning Liver biopsy Liver scanning When the body becomes jaundiced, a yellow skin discoloration results. When visualization of jaundice results, the total serum bilirubin exceeds 2.5 mg/dL. What types of information can be gleaned from the bilirubin values? The results provide information for diagnosis and evaluation of liver disease, biliary obstruction, erythroblastosis fetalis, and hemolytic anemia. What is the rationale for assessing liver enzymes? Why do their levels change with liver disease? Injury and diseases promote the release of intracellular enzymes into the bloodstream.

Laboratory and Diagnostic Examinations
(continued) Blood ammonia Hepatitis virus studies Serum amylase test Urine amylase test Ultrasound of pancreas Computerized tomography of the abdomen Endoscopic retrograde cholangiopancreatography of the pancreatic duct (ERCP) What nursing assessments must be performed before each of the listed diagnostic tests?

Disorders of the Liver, Biliary Tract, Gallbladder, and Pancreas
Cirrhosis Etiology/pathophysiology Chronic, degenerative disease of the liver Scar tissue restricts the flow of blood to the liver Types of cirrhosis Laennec’s cirrhosis Postnecrotic cirrhosis Primary biliary cirrhosis Secondary biliary cirrhosis Cirrhosis is the fourth leading cause of death in the United States for adults between 40 and 60. During its progression, cirrhosis causes the degeneration of liver tissue, which results in the formation of fibrous tissue and fat infiltration of the lobules. These events cause the reduction of blood flow, further compounding the problem. There are different types of cirrhosis. Discuss the different types of cirrhosis and their causes.

Cirrhosis (continued) Etiology/pathophysiology (continued) Alteration of liver function Reduced ability to metabolize albumin Obstruction of portal vein Increased pressure in veins that drain GI tract Complications Portal hypertension Ascites Esophageal varices Hepatic encephalopathy As cirrhosis continues to progress, there are resulting complications. These complications include portal hypertension, ascites, esophageal varices, and hepatic encephalopathy. What is the underlying cause of each of these?

Cirrhosis (continued) Clinical manifestations/assessment Early stages Abdominal pain Liver is firm and easy to palpate Late stages Dyspepsia Changes in bowel habits Nausea and vomiting Gradual weight loss When providing care to a patient diagnosed with cirrhosis, what nursing interventions are appropriate?

Cirrhosis (continued) Clinical manifestations/assessment (continued) Late stages (continued) Ascites Enlarged spleen Spider angiomas Anemia Bleeding tendencies Epistaxis As cirrhosis continues the physiological destruction of the liver, there is an increase in the severity of clinical manifestations. What factors should be assessed for the patient?

Cirrhosis (continued) Clinical manifestations/assessment (continued) Late stages (continued) Purpura Hematuria Bleeding gums Jaundice Disorientation What teaching should be provided to the patient concerning cirrhosis?

Systemic clinical manifestations of liver cirrhosis.
Figure 6-2 (From Lewis, S.M., Heitkemper, M.M., Dirksen, S.R. [2007]. Medical-surgical nursing: assessment and management of clinical problems. [7th ed.]. St. Louis: Mosby.) Systemic clinical manifestations of liver cirrhosis.

Cirrhosis (continued) Medical management/nursing interventions Pharmacological management Antiemetics Benadryl and Dramamine Contraindicated: Vistaril, Compazine, and Atarax Eliminate the cause Alcohol Hepatotoxins Environmental exposure to harmful chemicals The removal of the underlying causes of liver damage can aid in the prevention of additional damage to the structure. What is a commonly taken over-the-counter hepatotoxin? Antiemetics can be administered to reduce nausea and vomiting. What nursing assessments and diagnostic monitoring must accompany the administration of these medications?

Cirrhosis (continued) Medical management/nursing interventions (continued) Diet Well-balanced High in calories Moderate in protein Low in fat Low in sodium Supplemental vitamins and folic acid Diet management is vital in the treatment of cirrhosis. Ideally the diet should include between 2,500 and 3,000 calories per day. What are the goals of dietary modifications? Diet therapy is aimed at correcting malnutrition and promoting regeneration of the functional liver tissue and compensating for the liver’s deficits. What are the caloric needs of the patient diagnosed with cirrhosis?

Cirrhosis (continued) Medical management/nursing interventions (continued) Treatment of complications Ascites Bed rest Strict I&O Restrict fluids and sodium Diuretics: Aldactone, Lasix, HCTZ Vitamins K, C, and folic acid supplements LeVeen peritoneal-jugular shunt Paracentesis The severity of ascites will determine the medical management employed. At the very least, intake and output will be monitored. Diuretics can be prescribed. Review the mode of action for diuretics. If the ascites is severe, a paracentesis can be done. What nursing care should be performed before and after the procedure?

LeVeen continuous peritoneal jugular shunt.
Figure 6-3 The LeVeen shunt allows for continuous shunting of ascitic fluid from the abdominal cavity via a one-way, pressure-sensitive valve into a silicone tube and empties into the superior vena cava. What complications are associated with the use of the LeVeen shunt? Congestive heart failure, leakage of ascitic fluid, infection at the insertion site, peritonitis, septicemia, and shunt thrombosis. (From Beare, P.G., Myers, J.L. [1998]. Adult health nursing. [3rd ed.]. St. Louis: Mosby.) LeVeen continuous peritoneal jugular shunt.

Cirrhosis (continued) Medical management/nursing interventions (continued) Treatment of complications (continued) Ruptured esophageal varices Maintain airway; establish IV Vasopressin drip to control bleeding Sengstaken-Blakemore tube Endoscopic sclerotherapy Portacaval shunt Blood transfusion Esophageal varices occur because of portal hypertension. What is the primary goal of esophageal varices management? The avoidance of further bleeding and hemorrhage. What actions can result in bleeding or hemorrhage of the varices?

Cirrhosis (continued) Medical management/nursing interventions (continued) Treatment of complications (continued) Hepatic encephalopathy Decrease protein in diet Avoid drugs that are detoxified by the liver Lactulose Neomycin Hepatic encephalopathy is a type of brain damage caused by ammonia intoxication. What clinical manifestations can accompany this complication? In an effort to restrict protein and reduce ammonia formation in the intestines, dietary management might be needed. What foods would be appropriate for the diet of a patient experiencing hepatic encephalopathy? What foods should be avoided?

Liver cancer Etiology and pathology Hepatocellular carcinoma most commonly seen Cirrhosis of the liver and hepatitis C and B are also elevated risk factors In the United States liver cancer is seen more in people over age 40 Metastatic carcinoma of the liver is seen more than primary liver cancer Increases in liver cancer in the United States are tied to an increased incidence of hepatitis C.

Liver cancer Clinical manifestations Hepatomegaly Weight loss Peripheral edema Ascites Portal hypertension Dull epigastric pain Jaundice Anorexia

Liver cancer Diagnostic tests Liver scan Ultrasound CT scan Magnetic resonance imaging ERCP Liver biopsy Diagnosing liver cancer can be difficult.

Liver cancer Medical management/nursing interventions Palliative care Surgery Chemotherapy The prognosis for cancer of the liver is poor. What is the typical life expectancy for the patient with liver cancer? What nursing diagnoses would be appropriate for the patient diagnosed with liver cancer?

Hepatitis Etiology/pathophysiology Inflammation of the liver resulting from several types of viral agents or exposure to toxic substances Hepatitis A Most common Oral-fecal transmission Hepatitis A is the most common type of hepatitis. It is estimated that up to 50% of people in the United States are infected by the time they reach adulthood. What reporting is required of patients diagnosed with viral hepatitis? Identify situations in which a person could become infected with hepatitis A. List interventions to aid in the prevention of hepatitis A.

Hepatitis (continued) Etiology/pathophysiology (continued) Hepatitis B Transmission by contaminated serum; blood transfusion, contaminated needles, dialysis, or direct contact with infected body fluids Hepatitis C Transmitted through contaminated needles and blood transfusions Hepatitis B was formerly known as serum hepatitis. Hepatitis B is associated with a long incubation period.

Hepatitis (continued) Etiology/pathophysiology (continued) Hepatitis D Co-infection with hepatitis B Hepatitis E Fecal contamination of water Rare in the United States; usually in developing countries Hepatitis D is also known as delta virus. It causes hepatitis as a co-infection with hepatitis B. It can progress to cirrhosis and chronic hepatitis. Hepatitis E is also referred to as enteric non-A non-B hepatitis.

Hepatitis (continued) Clinical manifestations/assessment General malaise Aching muscles Photophobia Headaches Chills Abdominal pain Dyspepsia Nausea Provide a brief summation of the differences in the incubation periods for the types of hepatitis. The signs and symptoms of viral hepatitis vary greatly among patients.

Hepatitis (continued) Clinical manifestations/assessment (continued) Diarrhea/constipation Pruritus Hepatomegaly Enlarged lymph nodes Weight loss Jaundice Dark amber urine Clay-colored stools Two common clinical manifestations associated with hepatitis are pruritus and jaundice. What is the underlying cause of each of these symptoms?

Figure 6-5 Severe jaundice.
Review the key locations to assess the patient for jaundice. (From Kamal, A., Brockelhurst, J.C. [1991]. Color atlas of geriatric medicine. [3rd ed.]. St. Louis: Mosby-Year Book—Europe.) Severe jaundice.

Hepatitis (continued) Medical management/nursing interventions Treat symptoms Small, frequent meals Low-fat, high-carbohydrate IV fluids for dehydration Vitamin C, vitamin B–complex, vitamin K Avoid unnecessary medications, especially sedatives Management of the patient diagnosed with hepatitis is directed toward supportive therapy for the signs and symptoms and prevention of disease spread to others. Dietary management includes vitamin B, vitamin B–complex, and vitamin K. What is the rationale for these supplements for the patient with hepatitis?

Hepatitis (continued) Medical management/nursing interventions (continued) Gamma globulin or immune serum globulin Hepatitis B immune globulin (HBIG) Should be given to anyone exposed to hepatitis B Hepatitis B vaccine Should be given to people identified as high risk for developing hepatitis B Gamma globulin or immune serum globulin is a treatment geared toward patients who have been exposed to hepatitis B. When and how should these therapies be administered? Discuss the administration of the hepatitis B vaccine. Who are appropriate candidates for this medication? What is the prognosis for the patient who has been diagnosed with hepatitis?

Liver abscesses Etiology/pathophysiology May be single or multiple Abscess forms in the liver due to invading bacteria Liver abscesses can form if a bacterial infection can become colonized. What are potential sources of this infection?

Liver abscesses (continued) Clinical manifestations/assessment Fever Chills Abdominal pain and tenderness in the right upper quadrant Hepatomegaly Jaundice Anemia Patients having liver abscesses present with vague signs and symptoms. The most common complaints include fever, pain, and upper right quadrant tenderness. What nursing diagnoses would be appropriate for this patient?

Liver abscesses (continued) Diagnostic tests Radiograph Ultrasound CT scan Liver scan Medical management/nursing interventions IV antibiotic therapy Percutaneous drainage of liver abscess Open surgical drainage The prognosis for the patient with liver abscesses has improved over the past several years. What can be attributed to the improvements in clinical outcomes?

Cholecystitis and cholelithiasis Etiology/pathophysiology An obstruction, gallstone, or tumor prevents bile from leaving the gallbladder, and the trapped bile acts as an irritant, causing inflammation Risk factors Female; American Indian or white; obesity; pregnancy; diabetes; multiparous women; use of birth control In the United States, more than 500,000 patients are hospitalized with biliary system disorders.

Common sites of gallstones.
Figure 6-6 What are potential complications associated with this condition? (from Monahan, F.D., et al. [2007]. Phipps’ medical-surgical nursing: health and illness perspectives. [8th ed.]. St. Louis: Mosby.) Common sites of gallstones.

Cholecystitis and cholelithiasis (continued) Clinical manifestations/assessment Indigestion after eating foods high in fat Severe, colicky pain in the right upper quadrant Anorexia Nausea and vomiting Flatulence Increased heart and respiratory rates Diaphoresis The onset of symptoms might be sudden or demonstrated in a chronic manner with recurrent episodes of milder attacks. The clinical manifestations can cause the patient to believe he or she is experiencing a heart attack. Chronic attacks can be associated with the ingestion of a high-fat meal. Why does an elevated fat intake act as a catalyst for the attack?

Cholecystitis and cholelithiasis (continued) Clinical manifestations/assessment (continued) Low-grade fever Elevated WBC Mild jaundice Steatorrhea (fatty stool) Dark amber urine Objective data collected might reflect an elevated leukocyte count, clay-colored stools, and amber-colored urine. Review the pathology responsible for these findings.

Cholecystitis and cholelithiasis (continued) Medical management/nursing interventions Mild attacks Pharmacological management Antispasmodic and analgesic medications Antibiotics Bed rest NG tube to suction NPO IV fluids Dietary recommendations: Avoid spicy foods when allowed PO intake Management for mild attacks is typically conservative in nature. Conservative management seeks to rest the GI tract and the gallbladder. Pharmacological management includes antispasmodics, analgesics, and antibiotics. What is the rationale for each of the drug types prescribed? Review the rationale for the avoidance of morphine administration for patients experiencing biliary pain.

Cholecystitis and cholelithiasis (continued) Medical management/nursing interventions (continued) Lithotripsy Cholecystectomy Laparoscopic Open Lithotripsy and surgical management seek to break up or remove offending stones. What pre-procedure/preoperative patient education is needed for these patients? What are the nursing responsibilities for the postprocedure care of these patients?

Pancreatitis Etiology/pathophysiology Inflammation of the pancreas Acute or chronic Predisposing factors Alcohol Trauma Infectious disease Certain drugs Pancreatitis is in inflammation of the pancreas. It can be acute or chronic. Discuss the pathophysiologic processes of this disorder.

Pancreatitis (continued) Clinical manifestations/assessment Abdominal pain Anorexia; nausea and vomiting Malaise Low-grade fever Jaundice Weight loss Steatorrhea Tachycardia Patients having pancreatitis might express symptoms along a vast continuum. The most common is abdominal pain that radiates to the back. What is the root cause of the pain? What diagnostic tests can be used to support a diagnosis of pancreatitis?

Pancreatitis (continued) Medical management/nursing interventions Pharmacological management Antiemetics Analgesics Anticholinergics Antacids NPO IV fluids NG tube Hyperalimentation Unless the cause of pancreatitis is related to biliary tract disease, the management of the disease is medical. Foods and fluid are restricted. What is the rationale for this intervention? Parenteral anticholinergics may also be indicated. What is the rationale for the administration of this classification of medication? Dietary management for chronic pancreatitis might be initiated. What would characteristics of this diet be?

Cancer of the pancreas Etiology/pathophysiology Unknown Risk factors Cigarette smoking; exposure to chemical carcinogens; diabetes mellitus; pancreatitis; diet high in meat, fat, and coffee May be metastasis from the lung, stomach, duodenum, or common bile duct (CBD) May live only 4 to 8 months after diagnosis Pancreatic cancer is the fourth leading cause of cancer death in the United States and Canada. To what can the high death rate be attributed?

Cancer of the pancreas (continued) Clinical manifestations/assessment Anorexia Fatigue Nausea and flatulence Change in stools Steady, dull, aching pain in the epigastric area Weight loss Jaundice Onset of diabetes mellitus In addition to the assessment of physical signs and symptoms, the patient’s occupation should be investigated. What occupations would place a worker at higher risk of pancreatic cancer?

Cancer of the pancreas (continued) Medical management/nursing interventions Surgery Whipple procedure Total pancreatectomy with resection of parts of the GI tract Chemotherapy Radiation Review the diagnostic tests used to identify pancreatic cancer. What prognosis is associated with pancreatic cancer?

Whipple’s procedure, or radical pancreaticoduodenectomy.
Figure 6-9 (From Lewis, S.M., Heitkemper, M.M., Dirksen, S.R. [2007]. Medical-surgical nursing: assessment and management of clinical problems. [7th ed.]. St. Louis: Mosby.) Whipple’s procedure, or radical pancreaticoduodenectomy.

Nursing Process Nursing diagnoses Activity intolerance Noncompliance
Breathing pattern, ineffective Fluid volume, deficient Home maintenance, impaired Injury, risk for Knowledge, deficient Noncompliance Nutrition, imbalanced, less than body requirements Pain, acute/chronic Powerlessness Skin integrity, impaired Thought processes, disturbed

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