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Chapter 31

Chapter 31. Care of Patients with Disorders of the Gallbladder, Liver, and Pancreas. Theory Objectives. Explain the plan of care for the patient with cholelithiasis. Describe treatment for the patient with cholecystitis.

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Chapter 31

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  1. Chapter 31 Care of Patients with Disorders of the Gallbladder, Liver, and Pancreas

  2. Theory Objectives • Explain the plan of care for the patient with cholelithiasis. • Describe treatment for the patient with cholecystitis. • List the ways in which the various types of hepatitis can be transmitted. • Identify signs and symptoms of the various types of hepatitis.

  3. Theory Objectives (cont.) • Devise appropriate nursing interventions for the patient with cirrhosis and ascites. • Indicate potential causes of liver failure. • Differentiate the signs and symptoms of acute and chronic liver failure. • Describe the postoperative care of the patient who has undergone a liver transplantation.

  4. Theory Objectives (cont.) • Devise a nursing care plan for the patient with cancer of the liver. • Prepare a plan for adequate pain control for the patient with pancreatitis. • Compare the treatment options for cancer of the pancreas.

  5. Clinical Practice Objectives • Perform preoperative teaching for a patient who is to undergo laparoscopic cholecystectomy. • Write a nursing care plan, including psychosocial concerns, for the patient who has hepatitis with jaundice. • Design a discharge teaching plan for the patient who has been in the hospital with a flare-up of chronic pancreatitis. 

  6. Cholelithiasis and Cholecystitis • Etiology • Ethnic predisposition to gallstones • Pathophysiology • Signs and symptoms • None to severe and unbearable pain • Chronic cholecystitis is biliary colic

  7. Gallstones

  8. Cholelithiasis and Cholecystitis • Diagnosis • Ultrasonography • Computed tomography (CT) • Endoscopic retrograde cholangiopancreatography (ERCP) • Cholescintigraphy (hepatoiminodiacetic acid [HIDA] scan) • Liver function tests

  9. Comparison of Symptoms of Gallbladder Disorders • Pain/biliary colic • Nausea, vomiting • Indigestion and flatulence • Low-grade fever • Jaundice

  10. Cholelithiasis and Cholecystitis • Treatment • Diet • Correction of bile obstruction • Antibiotics • Post-cholecystectomy diet • Surgery • Complications

  11. Postoperative Laparoscopic Cholecystectomy • Remove the bandages from the puncture sites the day after surgery and shower • Report the following signs and symptoms should they occur: redness, swelling, bile-colored drainage or pus from any surgical site, severe abdominal pain, nausea, vomiting, chills, or fever, light-colored stool, dark urine, or yellow tint to the eyes or skin, as these signs may indicate obstruction of the flow of bile

  12. Postoperative Laparoscopic Cholecystectomy (cont.) • Normal activities may be resumed gradually • Return to work is probable at 1 week postsurgery • Stick to a low-fat diet for several weeks, slowly introduce fattier foods to determine if these cause unpleasant symptoms

  13. Nursing Management • Preoperative care • Postoperative care • Caring for a T-tube

  14. T-Tube

  15. Hepatitis • Etiology and pathophysiology • Types of viral hepatitis • HBV among Asian Americans • Signs and symptoms • Pre-icteric phase • Icteric phase • Post-icteric phase • Complications

  16. Comparison of Hepatitis-Causing Viruses • Transmission modes • Incubation periods • Infective periods • Signs and symptoms

  17. Diagnosis of Hepatitis • Serologic assays or enzyme immunoassays (EIAs) • Liver biopsy • Elevations in liver function tests (LFTs)

  18. Laboratory Tests • Aspartate aminotransferase (AST) • Alanine aminotransferase (ALT) • Gamma-glutamyl transpeptidase (GGT) • Bilirubin • Alkaline phosphatase • Serum albumin • Serum bilirubin (total) • Prothrombin time

  19. Treatment of Hepatitis • There is no specific treatment for acute viral hepatitis • Non-drug measures include well-balanced diet and rest, avoiding hepatotoxic substances including alcohol and certain medications • Active and passive immunity • Antiviral therapy

  20. Expected Outcomes • Patient will maintain body weight within normal limits during illness • Patient will verbalize lessened fatigue after rest periods each day • Patient will verbalize a decrease in pain after institution of nursing measures to decrease discomforts

  21. Expected Outcomes (cont.) • Patient will verbalize knowledge of disease process and self-care within 2 days • Patient will engage in appropriate diversional activities during convalescence

  22. Nursing Interventions • Monitor progress • Prevent the spread of infection • Patient/family teaching—proper handling of body secretions, proper hand hygiene, and limiting contact • Psychological support • Ensure adequate nutrition

  23. Prevention of Hepatitis • Home considerations for different types of viral hepatitis • Standard Precautions guidelines • Infection control

  24. Cirrhosis • Etiology • Postnecrotic cirrhosis • Laënnec’s cirrhosis or portal cirrhosis • Biliary cirrhosis • Cardiac cirrhosis • Liver-related deaths

  25. Cirrhosis (cont.) • Diagnosis • Liver biopsy • Liver function studies • CT and liver scan • Magnetic resonance cholangiopancreatography • Treatment—stopping the liver damage and restoring the liver’s functions

  26. Signs and Symptoms • Subjective symptoms • Fatigue • Weakness • Headache • Anorexia • Indigestion • Abdominal pain • Nausea • Vomiting

  27. Signs and Symptoms (cont.) • Fluid retention in the right hemithorax or ascites can limit expansion of the chest and cause dyspnea • Objective symptoms of liver cirrhosis include excessive gas, skin rashes, itching, and fever • Leg and foot edema and palmar erythema • Caput medusa • Bleeding and bruising

  28. Signs and Symptoms (cont.) • Deficiencies in vitamin K, thrombin, or prothrombin interfere with clot formation • The liver often is enlarged and “knobby” and is palpable below the level of the right rib cage • Abdominal distention • The spleen also enlarges

  29. Signs and Symptoms (cont.) • Peripheral edema and ascites • Skin lesions, jaundice, pruritus, bleeding disorders, endocrine disorders, and peripheral neuropathy occur in late disease • Spider angiomas may appear on the face, neck, upper trunk, and arms • The angiomas may blanch with pressure

  30. Signs and Symptoms of Cirrhosis

  31. Relationship of Systemic Portal Hypertension and Ascites in Cirrhosis

  32. Nursing Management of Cirrhosis • Assessment • Assess for safety issues • Laboratory tests • Alcohol withdrawal • Nursing diagnosis • Planning and implementation • Evaluation

  33. Complications of Cirrhosis • Esophageal varices • Encephalopathy • Delirium, convulsions, asterixis, and coma • Fetor hepaticus

  34. Blakemore-Sengstaken Tube

  35. Liver Transplantation • Legal and ethical considerations • Nursing management • Care of drains • Immunosuppressants • Liver function monitoring

  36. Cancer of the Liver • Etiology • Pathophysiology • Signs and symptoms • Diagnosis • Treatment • Nursing management

  37. Acute Pancreatitis • Etiology • Pathophysiology • Signs and symptoms • Diagnosis • Treatment • Nursing management

  38. Chronic Pancreatitis • Etiology and pathophysiology • Signs and symptoms • Diagnosis • Determination of bicarbonate concentration and output in the duodenum after stimulation with secretin is the definitive test for chronic pancreatitis

  39. Chronic Pancreatitis (cont.) • Treatment • Nursing management • Pain management • Complications including diabetes mellitus • Avoid alcohol

  40. Pathophysiology of Acute Pancreatitis

  41. Cancer of the Pancreas • Etiology • Pancreatic cancer deaths • Healthy gums for better pancreatic health • Pathophysiology • Cigarette smoking • Adenocarcinoma • Tumor in the head of the pancreas • Tumor in the body and tail of pancreas

  42. Cancer of the Pancreas (cont.) • Signs and symptoms • Deep vein thrombosis • Diagnosis • Ultrasonography, imaging techniques, and fine-needle biopsy • Elevated carcinoembryonic antigen levels • Serum beta-human chorionic gonadotropin and carbohydrate antigen (CA) 72-4 • Tumor markers CA 19-9 and CA 242

  43. Cancer of the Pancreas (cont.) • Treatment • Keep the patient comfortable • Treat or prevent malnutrition • Surgical treatment including Whipple procedure, or radical pancreaticoduodenectomy • Other treatments • Nursing management • Community care

  44. Audience Response Question 1 The nurse caring for a patient who has undergone radical pancreaticoduodenectomy should monitor for which postoperative complication(s)? (Select all that apply.) • Hypoglycemia • Hemorrhage • Bowel obstruction • Intra-abdominal abscess • Hyperkalemia

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