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Adult Health Nursing II Block 7.0 The Hepatobiliary System Diagnostic Tests I. Cholecystitis --Acute & Chronic --Cholecystectomy --T-Tubes II. Cancer of Gallbladder III. Pancreatitis --Acute & Chronic Nursing Assessment IV. Pancreatic Cancer V. Liver Disease --Cirrhosis --Liver Cancer Nursing Care Planning & Evaluation Block 7.0 Module 5.11 Learning Outcomes Discuss anatomy and physiology of the hepatobiliary system Distinguish pathophysiology of hepatobiliary disorders Discuss clinical manifestations in clients with hepatobiliary disorders Interpret laboratory findings and diagnostic testing for clients with hepatobiliary disorders Differentiate interventions and treatment options for clients with hepatobiliary disorders Block 7.0 Module 5.1 Learning Outcomes Discuss medication management of clients with hepatobiliary disorders Discuss complications associated with hepatobiliary disorders Prioritize nursing care for clients with hepatobiliary disorders Explore teaching plans for clients with hepatobiliary disorders Differentiate hepatobiliary disorders in the older adult Block 7.0 Module 5.1 Quick A & P Overview Block 7.0 Module 5.1 Quick A & P Overview Block 7.0 Module 5.1 The Biliary System Comprised Pancreas of Liver, Gallbladder, and Primary Functions: Secrete enzymes and other substances to promote food digestion Failure of these organs results in impaired digestion which may result in inadequate nutrition Block 7.0 Module 5.1 Gallbladder Disorders Function of the Gallbladder: --Collects, concentrates, and stores bile --Releases bile into duodenum when fat is present Cholecystitis- Acute and Chronic Cancer of the Gallbladder Block 7.0 Module 5.1 Gallbladder Block 7.0 Module 5.1 Cholecystitis Inflammation of the Gallbladder May be acute or chronic Acute Cholecystitis * 2 Types (Calculous & Acalculous) A. Calculous- Chemical Irritation and inflammation resulting from gallstones (cholelithiasis) that obstruct the cystic duct, gallbladder neck, or common bile duct. Exact pathophysiology of gallstones is unknown but cholesterol, bilirubin, calcium, and bile salts play a role in their formation Block 7.0 Module 5.1 Cholecystitis Acute Cholecytitis Acalculous- Inflammation occurring without gallstones. B. Biliary stasis due to any condition that affects filling or emptying of the gallbladder Block 7.0 Module 5.1 Cholecystitis Chronic Cholecysitis Repeated episodes of cystic obstruction Calculi are most always present Gallbladder becomes fibrotic and contracted resulting in decrease motility and deficient absorption Block 7.0 Module 5.1 Cholelithiasis (Gallstones) Block 7.0 Module 5.1 Clinical Manifestations Acute Sharp pain in right upper quad Pain with deep inspiration during right subcostal palpation (Murphy’s Sign) Rebound Tenderness (Blumberg’s Sign) Nausea, vomiting Loss of appetite Fever Eructation, Flatulence Chronic Jaundice- Yellow discoloration of the skin and mucous membranes due to increased bilirubin in the blood Icterus-Yellow discoloration of the sclera Pruritis- Accumulation of bile salts due to blockage of bile to the duodenum Clay colored stools Steatorrhea- (Fatty Stools) Block 7.0 Module 5.1 Jaundice Block 7.0 Module 5.1 Diagnostics RUQ Ultrasound- Most diagnostic test Abdominal X-Rays Hepatobiliary Scans Labs: Check your ATI Book Elevated WBC Elevated Direct, Indirect, and Total Bilirubin Elevated AST (with liver dysfunction) Elevated LDH (with liver dysfunction) Elevated Serum Cholesterol Block 7.0 Module 5.1 Nursing Interventions and Care History Dietary Counseling - Low fat diet - Promote weight reduction - Avoid gas-forming foods - Small , frequent meals Pain Management – Meperidine (Demerol) Antispasmodics Antiemetics Prepare for Pre and Post-Op Care Block 7.0 Module 5.1 Cholecystectomy Removal of the Gallbladder Nursing Care: Pain Management Encourage Splinting to reduce pain Fundamentals- turn, cough, deep breathe Monitor incision site Monitor and record T-Tube drainage-initially bloody then turns to green/brown bile Assess appetite and response to food Block 7.0 Module 5.1 Cholecystectomy Block 7.0 Module 5.1 T-Tube Ensures patency of common bile duct Limits fluid accumulation allowing duct to heal Surgically placed Remains up to 6 weeks post-op Nursing Care of a T-Tube- Iggy pg. 1370, Chart 62-2 Block 7.0 Module 5.1 The Older Adult May have Diabetes and have atypical presentation of symptoms (absence of pain or fever) Post Op period is of greater risk May have difficulty managing care of TTube at home May have difficulty modifying lifelong dietary patterns Block 7.0 Module 5.1 Cancer of the Gallbladder Rare, more common in women than men More common in American Indians (etiology unknown) Most cancers are adenocarcinoma and squamous cell Begin in inner layer of gallbladder (mucosa) and metastasize to outer organs: Liver, small intestine, and pancreas Prognosis is poor due to late diagnosis Block 7.0 Module 5.1 Cancer of the Gallbladder Clinical Manifestations Similar to cholecystitis Anorexia, wt loss Nausea, vomiting Abdominal Bloating Fever Malaise Jaundice- Advanced Enlarged liver and spleen Severe abdominal pain-advanced Treatment Surgery Radiation Chemotherapy Block 7.0 Module 5.1 Pancreas Functions: Exocrine: secrete enzymes for digestion Endocrine: Islets of Langerhans cells producing glucagon (Alpha cell) and insulin (beta cell) Block 7.0 Module 5.1 Pancreatitis Acute- Inflammation of the pancreas resulting from activated pancreatic enzymes autodigesting the pancreas Mortality can be as high as 20% Chronic – Progressive destruction of the pancreas with development of calcification and necrosis, possible resulting in hemorrahagic pancreatitis. Mortality can be as high as 50% Block 7.0 Module 5.1 Acute Pancreatitis Life threatening inflammatory process Patho: Premature activation of pancreatic enzymes that destroy ductal tissue and pancreatic cells Etiology- Mostly unknown however most common causes are: Excessive alcohol intake Biliary tract disease with gallstones Trauma-From surgical procedures Trauma-From diagnostic procedure-ERCP Familial Drug Use Block 7.0 Module 5.1 Clinical Manifestations Acute Pancreatitis Jaundice Ascites Severe, usually sudden onset abdominal/epigastric pain that radiates to back, left flank. Feels “boring” (a feeling like it is going thru the body) Nausea, Vomiting, Wt. loss Cullen and Turner signs Diagnostics Serum Amylase (30-110u/L) Rises within 12-24 hrs, last 4 days Serum Lipase (3-73u/L) Rises slower but last up to 2 weeks Lipase is usually more specific because the pancreas is the only organ that secretes lipase Urine amylase Decrease in serum calcium and magnesium Elevated WBCs Ultrasound and CT Block 7.0 Module 5.1 Acute Pancreatitis Cullen’s Sign Turner’s Sign Block 7.0 Module 5.1 Acute PancreatitisComplications Pancreatic infection (most common cause of death) Hypocalcemia Hypovolemia Type I diabetes-Total destruction of the pancreas Hemorrhage Septic Shock Paralytic ileus ARF Pneumonia, Atelectasis, Pleural Effusion, ARDS Coagulation defects- DIC Block 7.0 Module 5.1 Nursing Care Priority is provide supportive care by relieving symptoms and decreasing inflammation Always ABCs Pain Management-Opioids, Dilaudid and MS IV Fluids, I & O Rest GI Tract- NPO Nutrition- TPN NG Tube No Smoking No Alcohol Block 7.0 Module 5.1 Medication Management Spasmolytics- Pavabid, Cerespan Anticholinergics- Bentyl- Relieves spasms of muscles in the stomach and intestines , reduces spasms of Sphincter of Oddi (contraindicated in paralytic ileus) Histamine Receptor Antagonists (HCAs)-Suppress secretion of gastric acid by selectively blocking H2 receptors (Zantac) Protein Pump Inhibitors (PPIs)- Prilosec Pancreatic Enzymes- Increases digestion of fats, carbohydrates, and proteins in the GI tract Take immediately before meals with water Viokase, Donnazyme Antibiotics Block 7.0 Module 5.1 Chronic Pancreatitis Progressive disease with exacerbations and remissions Usually develops after repeated episodes of alcohol induced acute pancreatitis Also caused by chronic obstructive disorders of the common bile duct Loss of exocrine function-Digestive Enzymes Loss of endocrine function- Diabetes Block 7.0 Module 5.1 Chronic Pancreatitis Clinical Manifestations Intense abdominal pain that is continuous, burning or gnawing LUQ pain- ? Pseudocyst Steatorrehea or Clay color stools Weight loss Exacerbations Nursing Care Prevent exacerbation Pain Management Pancreatic enzymes Monitor I&O, IV fluids Education: pancreatic enzymes, diet, avoid smoking, caffeine, avoid alcohol, alcohol support groups Comfort measures Insulin therapy Monitor calcium levels Iggy pg. 1378 chart 62-3 Block 7.0 Module 5.1 Pancreatic Cancer Etiology-Unknown High incidence in age group 60-80 years High incidence in smokers 4th leading cause of cancer death in the U.S. Spreads rapidly through lymphatic and venous systems to other organs Vague symptoms usually diagnosed after there is already liver and gallbladder involvement High mortality rate- Less than 20% live longer than 1 year after diagnosis Block 7.0 Module 5.1 Clinical Manifestations Jaundice-May be first sign but signifies late stage of disease Fatigue Clay colored stools Dark urine Abdominal pain-vague Weight loss, nausea, vomiting GI bleeding Anorexia Splenomegaly- if spleen involved Hepatomegaly-if liver is involved Block 7.0 Module 5.1 Pancreatic CancerDiagnostics CT scan- visualization of the tumor Elevated serum amylase and lipase Elevated carcinoembryonic antigen (CEA) Elevated alkaline phosphatase and bilirubin ERCP- Most definitive- Allows for placement of a drain or stent for biliary drainage Abdominal Paracentesis- Drains fluid and tests for malignant cells Block 7.0 Module 5.1 Endoscopic Retrograde Cholangiopancreatography (ERCP) Block 7.0 Module 5.1 ERCP Block 7.0 Module 5.1 Pancreatic Cancer - Treatments Management is geared toward preventing tumor spread and decreasing pain. It is palliative not curative Surgery- Whipple Procedure -Removal of the head of the pancreas, duodenum, parts of the jejunum and stomach, gallbladder, and possibly the spleen. The pancreatic duct is connected to the common bile duct. The stomach is connected to he jejunum High Risk Follow with chemotherapy and radiation Block 7.0 Module 5.1 Nursing Care Post op care- Usually ICU with Whipple Procedure Pain management In addition to routine post op care: Assess glucose Assess bowel sounds and stools Assess for infections NPO- NG Tube TPN- Usually started pre-op *Assess for S+S of peritonitis- Board like abdomen *Assess fluids and electrolytes and other labs???? Block 7.0 Module 5.1 Liver Diseases Function of the Liver is to: Store Protect Metabolize Cirrhosis Liver Cancer Liver Transplants Hepatitis Block 7.0 Module 5.1 Liver (“Hepato-”) Disorders Block 7.0 Module 5.1 Cirrhosis Extensive irreversible scarring of the liver caused by a chronic reaction to hepatic inflammation and necrosis Block 7.0 Module 5.1 Cirrhosis Block 7.0 Module 5.1 Etiology Cirrhosis Alcohol (Laennec’s cirrhosis) Hepatitis B,C, and D (Post necrotic cirrhosis) Autoimmune hepatitis Steatohepatitis-(Fatty Liver Disease) Drugs and toxins Biliary disease Cardiac cirrhosis(Caused by Heart Failure) Clinical Manifestations Fatigue Significant change in wt Confusion or difficult thinking GI symptoms and GI Bleeding ABD and liver pain Pruritus Ascites Jaundice and Icterus Petechiae Palmar Erythema Spider Angiomas Fector hepaticus Dependent edema of extremities and sacrum Asterixis READ YOUR ATI BOOK Block 7.0 Module 5.1 Block 7.0 Module 5.1 Ascites Block 7.0 Module 5.1 Diagnostics Check Your ATI Book Serum Liver Enzymes- ALT, AST,ALP- All Increase Serum Bilirubin- Direct, Indirect, and Total- All Increase Serum Protein and Serum Albumin- Decrease CBC- Values Decrease (anemia) PT/INR- Increase Serum Ammonia- Increase Abdominal X-Rays, Ultrasound, CT, MRI EGD- Detect bleeding or esophageal varices Liver Biopsy- Most definitive-Measures progression and extent of cirrhosis Block 7.0 Module 5.1 Cirrhosis Secondary to Hepatitis Acute hepatitis A and acute hepatitis E do not lead to chronic hepatitis. Acute hepatitis B leads to chronic hepatitis infection in approximately 5% of adult patients. In a few of these patients, the chronic hepatitis B progresses to cirrhosis. Acute hepatitis D infects individuals already infected by hepatitis B. Acute hepatitis C becomes chronic in approximately 80% of adults. A minority of these patients (20-30%) will progress to cirrhosis, typically over many years. Block 7.0 Module 5.1 Nursing Care Comfort Measures Assess for Bleeding Complications- Blood Transfusions as ordered: Usually RBCs and FFP Diet and Dietary Teaching High Calorie, Moderate Fat Low-Sodium Low-Protein if encephalopathy and ^ ammonia levels Small-frequent feedings Vitamin Supplements Teach to Avoid Alcohol, MayBlock need Referrals 7.0 Module 5.1 Non-Surgical Management Paracentesis- Remove and drain ascitic fluid from the peritoneal cavity. Will relieve symptoms of fullness and respiratory distress Block 7.0 Module 5.1 Nursing Implications for Paracentesis Explain procedure and answer questions Obtain consent Monitor vital signs Monitor color and amount of drainage Send fluid to lab for analysis Abdominal girth measurements before and after Monitor puncture site for bleeding and serous fluid oozing Monitor respiratory status before and after Block 7.0 Module 5.1 Non-surgical Management TIPS- Transjugular Intrahepatic Portosystemic Shunt Used to control ascites and variceal bleeding Clients are discharged 2-4 days post procedure Block 7.0 Module 5.1 Medications Careful!!!!- Many medications metabolized in the liver. Caution with Opioids, Sedatives, Barbituates. Diuretics H2 Monitor for hypokalemia and hypotension receptor Antagonists- For Stress Ulcers Lactulose- stool Promotes excretion of ammonia via the Neomycin and Flagyl- Removes intestinal bacteria which produces ammonia Block 7.0 Module 5.1 Complications of Cirrhosis Portal Systemic Encephalopathy- Inability to remove ammonia causes increased toxins to the brain. Clients develop neurological symptoms Portal Hypertension Splenomegaly Esophageal Varices- Esophageal veins become distended due to increased pressure. Most often occur in the esophagus but can be present in stomach and rectum Bleeding Esophageal Varices is a life-threatening medical emergency. Client may vomit large amounts of blood (hematemesis) or possess large amounts of black tarry stools (melena) Block 7.0 Module 5.1 Esophageal Varices Treatment is endoscopic scleral therapy Use of a Blakemore Tube Block 7.0 Module 5.1 Portal Hypertension Hepatic encephalopathy Esophageal varices Peritonitis Metabolic and respiratory acid-base imbalance Systemic infections Malnutrition Death Block 7.0 Module 5.1 Portal Hypertension Block 7.0 Module 5.1 Block 7.0 Module 5.1 Hepatic Encephalopathy Clinical disorder seen in liver failure patients Results from shunting of portal venous blood and build up of toxic substances Ammonia crosses the blood brain barrier Stimulated by active GI bleeding Stages of Encephalopathy-Iggy- Pg. 1346 Table 61-2 Block 7.0 Module 5.1 Liver Cancer Most common Tumor is Hepatocellular Carcinoma (HCC) Most tumors are unresectable 5-year survival rate is less than 90% Risk Factors- Cirrhosis, Alcohol, HBV and HCV infections Block 7.0 Module 5.1 Diagnostics Alpha-fetoprotein (AFT) is elevated Serum Liver Enzymes-Elevated Ultrasound CT Liver Biopsy-Most definitive, High risk due to potential for bleeding Block 7.0 Module 5.1 Liver Cancer-Clinical Manifestations Abdominal Discomfort Weight Loss, Anorexia Jaundice S+S of Cirrhosis Enlarged liver Block 7.0 Module 5.1 Liver Transplant Most common reason for liver transplant is Hepatitis C Clients Not Considered Candidates: -Metastatic Tumors -Active alcohol/substance abuse -Severe cardiac & respiratory disease Can use a “lobe” of a liver for donation as the liver will regenerate itself 12 hour surgery Goal: Prevent rejection Rejection occurs 4-10 days post-op (liver failure), tachycardia, right upper flank pain, fever Block 7.0 Module 5.1 Liver Transplant Nursing Care Post Transplant: Monitor for S + S of rejection Cyclosporine Vaccinations and Antibiotics Post-Op Care- Infection, Pain, Fluid Management, Monitor for bleeding problems Psychosocial Support Block 7.0 Module 5.1 Hepatitis Hepatitis is inflammation of the liver Types: HAV, HBV, HCV, HDV, HEV, HFV, HGV- Iggy pgs 1356-1357 Viral Hepatitis can be acute or chronic Clients can NEVER donate blood, body organs, or tissue MUST report ALL cases of hepatitis to health department All healthcare workers should have Hep B vaccination series Block 7.0 Module 5.1 Risk Factors Ingestion of Contaminated Food or Water- A,E Drug Abuse-B,C,D Sexual Contact-B,C Transmission by Infected Healthcare Worker-B See ATI Chart- Pg 737 Block 7.0 Module 5.1 High Risk Behaviors Failure to Follow Universal Precautions Percutaneous Exposure- Sharps, Tattoos, Body-Piercing, Contaminated needles Unprotected Sex Unscreened Blood Transfusions (prior to 1992) Travel in underdeveloped countries without taking precautions (water) Crowded unsanitary environments TEACH!!!!!!!!!!!!!!! Block 7.0 Module 5.1 Diagnostics Lab Tests Serum liver enzymes-Elevated Serum bilirubin-Elevated Serologic markers-Presence of virus Hepatitis antibody serumIdentifies exposure Positive HBsAb indicates immunity to Hep B either following recovery or from successful vaccination Diagnostics Abdominal Films Liver biopsies-Most definitive Block 7.0 Module 5.1 Complications Chronic Hepatitis Fulminating hepatitis Cirrhosis of the liver Liver cancer Liver failure Block 7.0 Module 5.1 Hepatitis Nursing Interventions and Care Clinical Manifestations Influenza symptoms RUQ pain HBV: hepatomegaly, light color stools, dark urine, jaundice Assessment-Skin, eyes, pain History-Contacts, Travel Contact isolation Limit Activity Diet-High calorie Education to prevent transmission Drug therapy: Interferon( HBC,HCV) Monitor these clients for: -flu like symptoms -alopecia -bone marrow suppression -N&V Block 7.0 Module 5.1 End of Hepatobiliary Block 7.0 Module 5.1
