Chapter 6 Care of the Patient with a Gallbladder, Liver, Biliary Tract,

1. Chapter 6 Care of the Patient with a Gallbladder, Liver, Biliary Tract, or Exocrine Pancreatic Disorder

3. Liver, Biliary Tract, Pancreas, & Gallbladder Disorders • Cirrhosis • Etiology/pathophysiology • Chronic, degenerative disease of the liver • Scar tissue restricts the flow of blood to the liver • Types of cirrhosis • Laënnec’scirrhosis • Postnecrotic cirrhosis • Primary biliary cirrhosis • Secondary biliary cirrhosis

4. Liver, Biliary Tract, Pancreas, & Gallbladder Disorders • 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

5. LIVER

7. Liver, Biliary Tract, Gallbladder, & Pancreas Disorders • 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

8. Liver, Biliary Tract, Pancreas, & Gallbladder Disorders • Cirrhosis (continued) • Clinical manifestations/assessment (continued) • Late stages (continued) • Ascites • Enlarged spleen • Spider angiomas • Anemia • Bleeding tendencies • Epistaxis

9. Liver, Biliary Tract, Pancreas, & Gallbladder Disorders • Cirrhosis (continued) • Clinical manifestations/assessment (continued) • Late stages (continued) • Purpura • Hematuria • Bleeding gums • Jaundice • Disorientation

10. Figure 46-2 (From Lewis, S.M., Heitkemper, M.M., Dirksen, S.R. [2004]. Medical-surgical nursing: assessment and management of clinical problems. [6th ed.]. St. Louis: Mosby.) Systemic clinical manifestations of liver cirrhosis.

11. Liver, Biliary Tract, Pancreas, & Gallbladder Disorders • Cirrhosis (continued) • Medical management/nursing interventions • Eliminate the cause • Alcohol • Hepatotoxins • Environmental exposure to harmful chemicals • Antiemetics • Benadryl and Dramamine • Contraindicated: Vistaril, compazine, and Atarax

12. Liver, Biliary Tract, Pancreas, & Gallbladder Disorders • Cirrhosis (continued) • Medical management/nursing interventions (continued) • Diet • Well-balanced • High calorie • Moderate protein • Low fat • Low sodium • Supplemental vitamins and folic acid

13. Liver, Biliary Tract, Pancreas, & Gallbladder Disorders • Cirrhosis (continued) • Medical management/nursing interventions (continued) • Treatment of complications • Ascites • Bedrest • Strict I&O • Restrict fluids and sodium • Diuretics: aldactone, Lasix, HCTZ • Vitamins K, C, and folic acid supplements • LeVeen peritoneal-jugular shunt • Paracentesis

14. Figure 46-3 (From Beare, P.G., Myers, J.L. [1998]. Adult health nursing. [3rd ed.]. St. Louis: Mosby.) LeVeen continuous peritoneal jugular shunt.

15. Liver, Biliary Tract, Pancreas, & Gallbladder Disorders • 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

16. Liver, Biliary Tract, Pancreas, & Gallbladder Disorders • Cirrhosis (continued) • Medical management/nursing interventions (continued) • Treatment of complications (continued) • Hepatic encephalopathy • Decrease protein in diet • Avoid drugs which are detoxified by the liver • Lactulose • Neomycin

17. Liver, Biliary Tract, Pancreas, & Gallbladder Disorders • 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

18. Liver, Biliary Tract, Pancreas, & Gallbladder Disorders • Hepatitis (continued) • Etiology/pathophysiology • 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

19. Liver, Biliary Tract, Pancreas, & Gallbladder Disorders • Hepatitis (continued) • Etiology/pathophysiology (continued) • Hepatitis D • Co-infection with hepatitis B • Hepatitis E • Fecal contamination of water • Rare in the U.S.; usually in developing countries

20. HEPATITIS C

21. Liver, Biliary Tract, Pancreas, & Gallbladder Disorders • Hepatitis (continued) • Clinical manifestations/assessment • General malaise • Aching muscles • Photophobia • Headaches • Chills • Abdominal pain • Dyspepsia • Nausea

22. Liver, Biliary Tract, Pancreas, & Gallbladder Disorders • Hepatitis (continued) • Clinical manifestations/assessment • Diarrhea/constipation • Pruritus • Hepatomegaly • Enlarged lymph nodes • Weight loss • Jaundice • Dark amber urine • Clay-colored stools

23. Figure 46-5 Severe jaundice.

24. HEPATITIS

25. Liver, Biliary Tract, Pancreas, & Gallbladder Disorders • 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

26. Liver, Biliary Tract, Pancreas, & Gallbladder Disorders • 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

27. Liver, Biliary Tract, Pancreas, & Gallbladder Disorders • Liver abscesses • Etiology/pathophysiology • May be single or multiple • Abscess forms in the liver due to an invading bacteria

28. Liver, Biliary Tract, Pancreas, & Gallbladder Disorders

29. Liver, Biliary Tract, Pancreas, & Gallbladder Disorders • Liver abscesses (continued) • Clinical manifestations/assessment • Fever • Chills • Abdominal pain and tenderness in the right upper quadrant • Hepatomegaly • Jaundice • Anemia

30. Liver, Biliary Tract, Pancreas, & Gallbladder Disorders • Liver abscesses (continued) • Medical management/nursing interventions • IV antibiotics • Percutaneous drainage of liver abscess • Open surgical drainage

31. Liver, Biliary Tract, Pancreas, & Gallbladder Disorders • 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

32. Figure 46-6 Common sites of gallstones.

33. Liver, Biliary Tract, Pancreas, & Gallbladder Disorders • Cholecystitis and cholelithiasis 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

34. GALLSTONES

35. GALLSTONES

36. Liver, Biliary Tract, Pancreas, & Gallbladder Disorders • Cholecystitis and cholelithiasis (continued) • Clinical manifestations/assessment (continued) • Low-grade fever • Elevated WBC • Mild jaundice • Steatorrhea (fatty stool) • Dark amber urine

37. Liver, Biliary Tract, Pancreas, & Gallbladder Disorders • Cholecystitis and cholelithiasis • Medical management/nursing interventions • Mild attacks • Bedrest • NG tube to suction • NPO • IV fluids • Antispasmodic/analgesic • Antibiotics • Avoid spicy foods when allowed PO intake

38. Liver, Biliary Tract, Pancreas, & Gallbladder Disorders • Cholecystitis and cholelithiasis • Medical management/nursing interventions (continued) • Lithotripsy • Cholecystectomy • Laparoscopic • Open

39. Liver, Biliary Tract, Pancreas, & Gallbladder Disorders Pancreatitis Etiology/pathophysiology Inflammation of the pancreas Acute or chronic Predisposing factors Alcohol Trauma Infectious disease Certain drugs

40. Liver, Biliary Tract, Pancreas, & Gallbladder Disorders • Pancreatitis (continued) • Clinical manifestations/assessment • Abdominal pain • Anorexia; nausea and vomiting • Malaise • Low-grade fever • Jaundice • Weight loss • Steatorrhea • Tachycardia

41. Liver, Biliary Tract, Pancreas, & Gallbladder Disorders • Pancreatitis (continued) • Medical management/nursing interventions • NPO • IV fluids • NG tube • Antiemetics • Demerol 75-100 mg every 3-4 hours • Anticholinergics • Antacids or Tagamet (prevent ulcers) • Hyperalimentation

42. Figure 46-9 (From Lewis, S.M., Heitkemper, M.M., Dirksen, S.R. [2004]. Medical-surgical nursing: assessment and management of clinical problems. [6th ed.]. St. Louis: Mosby.) Whipple’s procedure, or radical pancreaticoduodenectomy.

43. NURSING PROCESS • NURSING DIAGNOSIS • Activity intolerance • Breathing pattern, ineffective • Fluid volume, deficient • Home maintenance, impaired • Injury, risk for • Knowledge, deficient

44. NURSING PROCESS • Noncompliance • Nutrition, imbalanced, less than body requirements • Pain, acute/chronic • Powerlessness • Skin integrity, impaired • Thought processes, disturbed

45. QUOTE • "Don't procrastinate. Putting off an unpleasant task until tomorrow simply gives you more time for your imagination to make a mountain out a possible molehill. More time for anxiety to sap your self-confidence. Do it now, brother, do it now. " Author Unknown, from Ten Ways to Worry Less and Accomplish More

46. Chapter 24 Agents Used to Treat Hyperacidity and Gastroesophageal Reflux Disease

47. Secretory Functions of the Stomach Lining • Parietal cells secrete hydrochloric (HCl) acid • Chief cells secrete pepsinogen • Mucoid cells secrete mucus

48. Stomach Hyperchlorhydria • Produced from: • Eating high-fat meals • Increased alcohol intake • Emotional turmoil

49. Goal of Antacid Therapy • Neutralize the acid • Inhibit pepsin activity • Increase resistance of the stomach lining • Increase tone of the lower esophageal sphincter

50. Antacids • Three Forms • Aluminum • Magnesium • Calcium • Mechanism of action • Neutralization of gastric acidity • Low doses promote gastric mucosal defensive mechanisms