Chapter 6 Care of the Patient with a Gallbladder, Liver, Biliary Tract, or Exocrine Pancreatic Disorder Mosby items and derived items © 2011, 2007 by Mosby,

Chapter 6Chapter 6

Care of the Patient with a Gallbladder, Liver, Biliary Tract, or Exocrine Pancreatic Disorder

Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Slide 2Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Laboratory and Diagnostic ExaminationsLaboratory 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


Laboratory and Diagnostic ExaminationsLaboratory 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)


Disorders of the Liver, Biliary Tract, Gallbladder, and PancreasDisorders 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 (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



• 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



• Cirrhosis (continued) Clinical manifestations/assessment (continued)

• Late stages (continued) Ascites Enlarged spleen Spider angiomas Anemia Bleeding tendencies Epistaxis



• Cirrhosis (continued) Clinical manifestations/assessment (continued)

• Late stages (continued) Purpura Hematuria Bleeding gums Jaundice Disorientation


Figure 6-2Figure 6-2

Systemic clinical manifestations of liver cirrhosis.

(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.)



• Cirrhosis (continued) Medical management/nursing interventions

• Pharmacological management Antiemetics

o Benadryl and Dramamineo Contraindicated: Vistaril, Compazine, and Atarax

• Eliminate the cause Alcohol Hepatotoxins Environmental exposure to harmful chemicals




(continued)• Diet

Well-balanced High in calories Moderate in protein Low in fat Low in sodium Supplemental vitamins and folic acid




(continued)• Treatment of complications

Asciteso Bed resto Strict I&Oo Restrict fluids and sodiumo Diuretics: Aldactone, Lasix, HCTZo Vitamins K, C, and folic acid supplementso LeVeen peritoneal-jugular shunto Paracentesis



LeVeen continuous peritoneal jugular shunt.

(From Beare, P.G., Myers, J.L. [1998]. Adult health nursing. [3rd ed.]. St. Louis: Mosby.)




(continued)• Treatment of complications (continued)

Ruptured esophageal variceso Maintain airway; establish IVo Vasopressin drip to control bleedingo Sengstaken-Blakemore tubeo Endoscopic sclerotherapyo Portacaval shunto Blood transfusion




(continued)• Treatment of complications (continued)

Hepatic encephalopathyo Decrease protein in dieto Avoid drugs that are detoxified by the livero Lactuloseo Neomycin



• 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



• 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



• Liver cancer Medical management/nursing interventions

• Palliative care

• Surgery

• Chemotherapy



• 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 (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 (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 (continued) Clinical manifestations/assessment

• General malaise

• Aching muscles

• Photophobia

• Headaches

• Chills

• Abdominal pain

• Dyspepsia

• Nausea



• Hepatitis (continued) Clinical manifestations/assessment (continued)

• Diarrhea/constipation

• Pruritus

• Hepatomegaly

• Enlarged lymph nodes

• Weight loss

• Jaundice

• Dark amber urine

• Clay-colored stools



Severe jaundice.

(From Kamal, A., Brockelhurst, J.C. [1991]. Color atlas of geriatric medicine. [3rd ed.]. St. Louis: Mosby-Year Book—Europe.)



• 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



• 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



• Liver abscesses Etiology/pathophysiology

• May be single or multiple

• Abscess forms in the liver due to invading bacteria



• Liver abscesses (continued) Clinical manifestations/assessment

• Fever

• Chills

• Abdominal pain and tenderness in the right upper quadrant

• Hepatomegaly

• Jaundice

• Anemia



• 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



• 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



Common sites of gallstones.

(from Monahan, F.D., et al. [2007]. Phipps’ medical-surgical nursing: health and illness perspectives. [8th ed.]. St. Louis: Mosby.)



• 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



• Cholecystitis and cholelithiasis (continued) Clinical manifestations/assessment (continued)

• Low-grade fever

• Elevated WBC

• Mild jaundice

• Steatorrhea (fatty stool)

• Dark amber urine



• Cholecystitis and cholelithiasis (continued) Medical management/nursing interventions

• Mild attacks Pharmacological management

o Antispasmodic and analgesic medicationso Antibiotics

Bed rest NG tube to suction NPO IV fluids Dietary recommendations: Avoid spicy foods when

allowed PO intake



• Cholecystitis and cholelithiasis (continued) Medical management/nursing interventions

(continued)• Lithotripsy

• Cholecystectomy Laparoscopic Open



• Pancreatitis Etiology/pathophysiology

• Inflammation of the pancreas Acute or chronic

• Predisposing factors Alcohol Trauma Infectious disease Certain drugs



• Pancreatitis (continued) Clinical manifestations/assessment

• Abdominal pain

• Anorexia; nausea and vomiting

• Malaise

• Low-grade fever

• Jaundice

• Weight loss

• Steatorrhea

• Tachycardia



• Pancreatitis (continued) Medical management/nursing interventions

• Pharmacological management Antiemetics Analgesics Anticholinergics Antacids

• NPO

• IV fluids

• NG tube

• Hyperalimentation



• 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



• 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



• Cancer of the pancreas (continued) Medical management/nursing interventions

• Surgery Whipple procedure Total pancreatectomy with resection of parts of the GI

tract

• Chemotherapy

• Radiation



Whipple’s procedure, or radical pancreaticoduodenectomy.

(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.)


Nursing ProcessNursing Process

• Nursing diagnoses Activity intolerance 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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Chapter 6 Care of the Patient with a Gallbladder, Liver, Biliary Tract, or Exocrine Pancreatic Disorder Mosby items and derived items © 2011, 2007 by Mosby,