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Med/Surg II,
Part 3 of 4
Digestion Disorders
Malignant Oral and Laryngeal Tumors
1
Pre-Malignant Mouth Lesions


Leukoplakia: pre-malignant lesion, especially
on tongue or lips; thickened, white, permanently
attached patches, slightly raised, sharp edges
Erythroplakia: pre-malignant lesion more likely
to progress to malignancy than leukoplakia; red,
velvety lesion found in floor of mouth, tongue,
palate, mandible mucosa
2
Squamous Cell Mouth Carcinoma

Risk Factors



Increased age
Tobacco (chewing or smoking)
Treatment


Early detection is most important
Local excision will be done if possible for biopsy and
possible cure.
3
Diagnosis of Laryngeal Cancer



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
Direct laryngoscopy
CT scan of the head and neck with contrast
MRI of head and neck with contrast
PET scan:
Biopsies


Endoscopic biopsy
Fine needle aspiration (FNA) biopsy
4
Total Laryngectomy, Preoperative Care







Discuss the informed consent
Explain that the procedure will likely be many hours
Intensive care unit for airway protection - may be on
a ventilator.
Alternate forms of communication
Prepare the patient for a feeding tube
Explain pain control methods: PCA machine. Have
the patient practice with one if possible.
Tracheostomy will probably be performed - explain
this to the patient.
5
Postoperative Care
Airway Maintenance
Flap and reconstructive tissue care
Hemorrhage
Wound breakdown
Pain management
Nutrition
Speech rehabilitation
6
Discharge Teaching
Stoma Care






Avoid swimming, care with showering or shaving to
protect stoma opening
Lean slightly forward, cover stoma when coughing or
sneezing
Wear a stoma guard
Clean the stoma with mild soap & water. Lubricate
with non-oil-based ointment prn
Increase humidity in airway with saline spray, humidifier
in room
Wear a Med-Alert bracelet & carry emergency care card
7
Communication



Verify the patient knows how to use his selected
communication method
Keep backup communication options available
Card that explains the patient’s situation in an
emergency: http://www.larynxlink.com/
8
Resources
 Smoking
cessation support
 Speech therapy
 Dietician
 Laryngectomy support group
 Alcoholics Anonymous if needed
9
Psychosocial Preparation




A visit from a fellow laryngectomee
Importance of returning to a normal lifestyle as
much as possible
Expect changes in smell & taste as well as
communication
Prepare for mucus with handkerchiefs, tissues or
gauze
10
Esophageal Problems
Gastroesophageal Reflux Disease
(GERD)
Esophageal Cancer
11
Clinical Manifestations of GERD





Pyrosis
Dyspepsia - may mimic symptoms of a
myocardial infarction
Regurgitation of food particles or fluid – sour or
bitter taste in mouth – high risk aspiration
Dysphagia
Hypersalivation
12
Collaborative Management: Diet




Limit or eliminate chocolate, fat, mints,
carbonated drinks
Limit spicy and acidic foods when symptomatic
Eat 4-6 small meals per day
Avoid evening snacks, no food 3 hours before
sleeping
13
Lifestyle Changes





Elevate head of bed at least 6 inches to avoid
reflux when sleeping
Sleep in left lateral decubitus position
Smoking and alcohol exacerbate reflux
Weight reduction will decrease intra-abdominal
pressure
Avoid any activity that increases abdominal
pressure
14
Medication



Antacids for occasional episodes raise gastric pH:
Gaviscon, Maalox, Mylanta one hour before and 2-3
hours after a meal
Histamine receptor antagonists reduce acid secretion:
ranitidine (Zantac), famotidine (Pepcid)
Proton pump inhibitors are the main treatment for
GERD: omeprazole (Prilosec), lansoprazole (Prevacid),
pantoprazole (Protonix), esomeprazole (Nexium)
15
Esophageal Cancer


Risk Factors: Chronic irritation: smoking,
alcohol ingestion, GERD
Manifestations: progressive and persistent
dysphagia (most common), sense of mass in
throat, painful swallowing (odynophagia),
substernal pain or fullness, regurgitation with
foul breath and hiccups and weight loss
16
Diagnosis


Barium swallow with
fluoroscopy
Esophagogastroduodenos
copy (EGD) with biopsies
(definitive diagnosis)
Image Source: National Cancer Society, Public Domain,
http://visualsonline.cancer.gov/
17
Esophageal Reconstruction
Postoperative Nursing Care

Highest priority




Stress deep breathing
Incentive spirometer
Early ambulation
Semi-fowler’s position in
bed
18
Cardiovascular

Monitor closely for:

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
Hypotension from hypovolemia
Pulmonary edema from fluid overload
Chest tube management if present
19
Wound management

Multiple incisions and drains


Support incision when moving to prevent dehiscence
Infection from incision leak

Watch for fever, increased fluid from drains, signs of
local inflammation, tachycardia
20
Nasogastric tube

Placed intraoperatively to decompress suture
area


Do not irrigate or reposition.
Drainage bloody early, green-yellow after 24
hours
21
Nutrition






Jejunal tube placed intraoperatively
Start tube feeding after 24 hours, increase slowly
When taking oral nutrition, start with liquids and
advance slowly to accommodate decreased stomach
capacity
Teach: always eat in upright position – to protect
against reflux
Eat 6-8 small meals per day
No liquids with meals to prevent diarrhea (dumping
syndrome)
22
Stomach Disorders
Peptic Ulcer Disease (PUD)
Gastric Carcinoma
23
Peptic Ulcer Disease (PUD)


Risk Factors
Acute gastritis caused by:


Helicobacter pylori, a gram-negative bacterium
Medication side effect: Nonsteroidal antiinflammatory drugs, alcohol, cytotoxic agents,
caffeine, corticosteroids
24
Prevention




Avoid excess alcohol
Use caution with inflammatory medications
Avoid excess caffeine
Stop smoking
25
Manifestations


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Epigastric pain
Anorexia, nausea or vomiting
Hematemesis
Dyspepsia
Intolerance of fatty and spicy foods
26
Collaborative Treatment

Teach: Stress reduction, avoid alcohol and
tobacco

Diet:
 Limit any foods or spices that cause symptoms
 Avoid bedtime snacks (stimulate acid
secretion)
27
Drugs



H. pylori: Treat with 2 antibiotics +
bismuth compound (Pepto-Bismol) or
proton pump inhibitor
Antacids 2 hours after meals to buffer acid
secretions.
H2- receptor blockers to prevent acid
secretions
28
Drugs
(continued)
 Mucosal
barrier, sucralfate (Carafate)
 Antisecretory agents
 Prostaglandin analogues such as
misoprostol (Cytotec) to decrease acid
secretion and increase mucosal
resistance
29
Manage Complications



Bleeding: Watch for coffee ground
vomitus; black, tarry stools (melena) as
well as bright red blood
Monitor hemoglobin, hematocrit,
coagulation studies
Monitor vital signs for shock
30
Manage Complications
 Nasogastric

lavage:
NOTE: use 0.9% saline NOT tap
water
31
Hypovolemia from Bleeding
 Isotonic
crystalloids (0.9% saline,
Ringer’s lactate), blood products,
electrolytes as indicated
 Watch! for metabolic alkalosis due to
acid loss from vomiting.
32
Assist physician with EGD

Patient preparation:




Large-bore IV catheter for conscious sedation
Blood products if needed
NPO for at least 6 hours, informed consent
Post-procedure: monitor vital signs, oxygen
33
Surgical Management




Vagotomy
Pyloroplasty
Billroth I
(gastroduodenostomy)
Billroth II
(gastrojejunostomy)
Image Source: www.healcentral.rog, Royal College of Surgeons of Ireland, Creative Commons
http://www.healcentral.org/healapp/searchResults?searchtype=simple&display=25&keywords=vagotomy&page=1
34
Postoperative Management:



Nasogastric Tube: Attach securely to maintain
position – do not change position without
surgeon’s order
Monitor drainage for color, volume of drainage
NOTE: report more than scant bloody drainage
or minimal drainage; do not irrigate.
35
Dumping Syndrome


Early manifestations: vertigo, tachycardia,
syncope, sweating, pallor, palpitations.
Late (90 minutes to 3 hours after eating):
excessive insulin release causes dizziness,
palpitations, diaphoresis, confusion.
36
Management: Dumping Syndrome





Eat small amounts
Eliminate liquids at meals
High-protein, high-fat, low-carbohydrate diet
Powdered pectin may prevent symptoms
Octreotide (Sandostatin) prescribed in severe
cases to inhibit hormones that cause symptoms
37
Alkaline Reflux Gastropathy


Bile reflux in patients whose pylorus is bypassed
or removed (Billroth procedures)
Symptoms of early satiety, abdominal
discomfort, vomiting.
38
Delayed Gastric Emptying


Often present after gastric surgery, usually
resolves within one week.
Continued nasogastric suction relieves
symptoms until resolved.
39
Afferent Loop Syndrome


If duodenal loop is partially obstructed after a
Billroth II, pancreatic and biliary secretions fill
the loop, distending it.
Monitor for abdominal bloating, pain 20-60
minutes after eating followed by nausea and
vomiting. Surgical correction is necessary.
40
Nutrition




Decreased absorption of calcium and vitamin D.
At risk for pernicious anemia.
Give vitamin B12 injection
May need folic or iron replacement.
41
Gastric Carcinoma:
Risk
Factors
 H. pylori
infection, untreated





Pernicious anemia
Gastric polyps
Achlorhydria
Chronic atrophic gastritis
Cigarette smoking, alcohol consumption are
controversial
42
Manifestations

Early:




Indigestion
Abdominal discomfort, feeling of fullness
Epigastric, back, or retrosternal pain
Late:






Nausea and vomiting
Obstructive symptoms, enlarged lymph nodes
Iron deficiency anemia
Palpable epigastric mass
Enlarged lymph nodes
Progressive weight loss
43
Surgical Management

Subtotal or total gastrectomy: stomach,
or portion, is removed and duodenum,
or remainder of stomach, is sutured to
esophagus
44
Postoperative Care


Decompress wound: maintain patency and
suction from NG tube to keep pressure off
sutures and prevent anastomosis leakage
Notify surgeon if reposition or irrigation
needed.
45
Postoperative Care
(continued)


Assess color, amount, odor of NG drainage:
notify surgeon of any changes
Color should change from dark red to greenyellow over the first 2-3 days
46
Postoperative Care
(continued)

Replace fluids and electrolytes intravenously:



At risk for dehydration,
Imbalances of sodium, potassium, chloride
Metabolic alkalosis.
47
Postoperative Care
(continued)

Anti-ulcer and antibiotic therapy: prevention
of stress ulcers and prophylaxis against any
gastric contamination of the abdominal
cavity.
48
Postoperative Care
(continued)


Monitor abdomen: listen for bowel sounds,
watch for distention – may be third spacing,
obstruction or infection.
Encourage ambulation to stimulate peristalsis.
49
Nutrition


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Total parenteral nutrition (TPN)
Enteral feeding postoperatively
Oral feedings: prevent regurgitation from
overeating or eating too quickly.
Watch for dumping syndrome.
Treat anemia, vitamin B12, and folate deficiency.
Teach: recurrence of cancer is common – need
regular follow-up.
50
Disorders of the Intestine
Irritable Bowel syndrome (IBS)
Hernias
Colorectal Cancer
51
Irritable Bowel Syndrome (IBS)

Typical manifestations:




Abdominal pain relieved by defecation or associated
with changed stool frequency or consistency
Abdominal distention
Sensation of incomplete stool evacuation
Mucus in stool
52
Collaborative Management







Identify food intolerances
Add fiber to diet (bran)
Avoid lactose, fructose or sorbitol (often cause
problems)
Avoid gas-forming foods
Limit caffeinated drinks (GI stimulants)
Evacuate promptly
Stress and anxiety reduction
53
Medications

Constipation prominent:



Diarrhea prominent:



GI prokinetics
Bulk laxatives at meals with water
loperamide (Imodium) or
diphenoxylate (Lomotil)
Abdominal pain prominent:

Anticholinergic before meals to prevent spasm:
dicyclomine (Antispas, Bentyl, Asacol)
54
Hiatal Hernia

Clinical Manifestations





Heartburn (reflux)
Dysphagia, belching
Feeling of fullness or breathlessness after eating
Feeling of suffocation
Worsening of symptoms when lying down
55
Prevention




Remain upright several hours after eating
Avoid straining
Sleep with head elevated
Weight loss to decrease abdominal pressure
56
Medical Management



Frequent small feedings
No reclining for 1 hour after eating
Control reflux
57
Postoperative Nursing Care




NG placed in OR, no moving!
Expect temporary dysphagia – gradual increase
in diet
Gas bloat syndrome – inability to belch –
avoid gas producing foods, gum, drinking with
straw
Aerophagia (air swallowing) habit – retrain or
use simethicone to reduce bloating
58
Inguinal Hernia






Bulge, lump or swelling in groin
Sharp pain or dull ache radiating to scrotum or
vagina
Mass felt with standing or straining
Reducible
Irreducible (incarcerated)
Strangulated
59
Prevention


Weight control
Avoid heavy lifting and straining
60
Medical Management

A truss is prescribed for inguinal hernias. A
firm pad placed over hernia attached to a belt to
keep intestine from protruding
61
Postoperative Nursing Care





Difficulty voiding
Scrotal support
Ice bags to scrotum or vaginal area
Elevate scrotum on soft pillow
Teach: avoid heavy lifting, straining for 3 weeks
62
Colorectal Cancer
Image Source: National Cancer Society, Public Domain,
http://visualsonline.cancer.gov/
63
Prevention



Avoid fat or fatty foods, low-fiber
foods, refined carbohydrates
Consume fruits and vegetables,
especially cabbage family; whole
grains, adequate water, baked or
poached fish and poultry
Avoid chronic bowel inflammation
64
Early Detection
Genetic testing for familial risk
 Yearly occult blood testing of stool, -or Flexible sigmoidoscopy every 5 years, -or Double-contrast barium enema every 5 years,
-or Colonoscopy every 10 years

65
Manifestations




Rectal bleeding (hematochezia) with anemia
Narrowing of stool, change in bowel habits
Signs and symptoms of bowel obstruction: gas
pain, cramping, incomplete evacuation, highpitched tinkling bowel sounds in waves
Dull abdominal pain
66
Colorectal Cancer Staging
Image Source: National Cancer Society, Public Domain,
http://visualsonline.cancer.gov/
67
Fiberoptic Colonoscopy


Colon preparation
During procedure


Conscious sedation
Care after Procedure



Watch! Bowel perforation
Polyp removal
Expect amnesia: written instructions, no driving!
Image Source: National Cancer Society, Public Domain,
http://visualsonline.cancer.gov/
68
Colostomy
Image Source: National Cancer Society, Public Domain,
http://visualsonline.cancer.gov/
69
Preoperative preparation






Clear liquids for 1-2 days
Mechanical bowel cleansing
Prophylactic antibiotics
Colostomy placement
Instruct in general principles of ostomy care
Nasogastric tube
70
Postoperative care:
Colostomy management




Assess stoma color, integrity, drainage
Keep periostomal skin clean, dry
Place close-fitting pouch over stoma - monitor
for leakage
Empty pouch frequently, remove gas buildup
71
Perineal Wound Care





Bulb suction drains: monitor amount, color,
odor of drainage
Absorbent dressing
Rectal pain and itching
Teach: use side-lying position, avoid long
periods of sitting using soft pillow
Do NOT use air ring or donut devices – will cut
off circulation to wound
72
Discharge Teaching



Refer to local ostomy association.
Ostomy supplies
Instruct





Placing a drainage bag
Assessing and cleansing the stoma, irrigation
Signs of infection
Nutrition: avoid odor and gas-causing foods
Develop a plan: constipation or diarrhea
73
Inflammatory Bowel
Disease
Ulcerative Colitis
Crohn’s Disease
Appendicitis
Peritonitis
Diverticular Disease
74
Ulcerative Colitis







Begins in rectum, proceeds toward cecum; affects
only superficial layers
Age 15-25 & 55-65
10-20 liquid, bloody stools per day
Stools occult blood positive
Very ↓ hemoglobin, ↑ WBCs
↓ sodium, potassium, chloride, albumin
Barium enema: incomplete filling, fine ulcerations
75
Complications




Hemorrhage
Bowel perforation
Fistulas
Nutritional deficiencies
76
Crohn’s Disease






Mostly terminal ileum, patchy through all layers of the
bowel
Age 15-40
5-6 soft, loose stools per day, rarely bloody
↓ hemoglobin, ↑ WBCs, ↓ albumin
Upper GI series: “string sign” of constricted terminal
ileum
Decreased folic acid, vitamins A, B complex, C
77
Complications


Fistula
Nutritional deficiencies
78
Collaborative Management


Medication: to rest the bowel
Nutrition:




Fluids, low-residue, high-protein, high-calorie diet
Vitamin and iron supplements
Avoid foods that cause diarrhea
Avoid cold foods and smoking: increase intestinal
motility
79
Colectomy


Total colectomy with an ileal pouch-anal
anastomosis (IPAA). A pouch is formed from
the terminal ileum and connected to the anal
canal.
Continent (Kock’s) ileostomy.
Image Source: National Cancer Society, Public Domain,
http://visualsonline.cancer.gov/details.cfm?imageid=3901
80
Preoperative Care





Similar to colostomy
Fluids, blood & protein if losses severe
Low residue diet, frequent small feedings
Antibiotics to treat inflammation, cleanse bowel
Stoma right lower quadrant about 2 inches
below waistline
81
Postoperative Care






Apply a pouch with meticulous skin care
Assess stoma for bleeding, color
Monitor stool production
Empty pouch when no more than 1/3 full
Emphasize fluid and salt intake
High potassium, low-residue diet, avoid gas-producing
or high fiber foods to prevent blockage


Signs of blockage: abdominal cramps, swelling of stoma, no
output over 4-6 hours
Relieve blockage prn
82
Irrigate continent ileostomy
(Kock pouch)




Insert catheter into pouch, drain every 4-6 hours
Irrigate once daily with normal saline.
No external pouch is necessary
Amount of stool will increase as pouch stretches.
83
Appendicitis





Epigastric or peri-umbilical
cramping
Nausea followed by vomiting
Pain becomes more steady and
severe, migrates to right lower
quadrant (McBurney’s point)
Rebound tenderness
Signs of perforation
Photo Source: Wikimedia Commons, Creative Commons,
http://commons.wikimedia.org/wiki/Image:Tractus_intestinalis_ap
pendix_vermiformis.svg
84
Peritonitis







Rigid, board-like abdomen (classic)
Pain: general abdominal, may spread to
shoulders or chest
Distended abdomen
Nausea, vomiting
Decreased bowel sounds
Rebound abdominal tenderness
High fever, tachycardia
85
Collaborative Management





NPO with intravenous fluids
Broad spectrum intravenous antibiotics
Nasogastric tube to decompress stomach
Oxygen
Pain management
86
Exploratory Laparotomy






Abdomen is flushed with saline and lavaged with
antibiotic solution.
Postoperative Care:
Position
Manage wound and drains
If wound irrigation ordered, use sterile
technique
Replace lost fluids and electrolytes
87
Diverticular Disease


Small outpouchings of the colon, 90% in the
sigmoid colon, that can become infected
resulting in diverticulitis, or rupture, resulting in
peritonitis.
Risk Factors:



Diet: highly refined, fiber-deficient
Decreased physical activity
Poor bowel habits with constipation
88
Manifestations




Episodic left-sided abdominal cramping or
steady pain
Constipation alternating with diarrhea
Narrow stools with bright red blood
Diverticulitis: if undigested food and bacteria
collect in the diverticula, inflammation results
89
Collaborative Management






Broad-spectrum antibiotics
Pain relief: patient-controlled analgesia with
opiate
Bulk-forming products: psyllium seed
(Metamucil)
Bowel rest during acute episode
Assess for decreased bowel sounds, abdominal
distention, tenderness: peritonitis from bowel
rupture
Assess for lower GI bleeding
90
Teach



Avoid laxatives
Eat a high-fiber diet
Avoid: wheat and corn bran, vegetable and
fruit skins, nuts, dry beans
91
Liver Disorders
Cirrhosis
Hepatitis
92
Cirrhosis








Portal hypertension
Ascites
Esophageal varices
Coagulation defects
Jaundice
Encephalopathy
Hepatorenal syndrome
Spontaneous bacterial peritonitis
93
Clinical Manifestations




Massive ascites: distended abdomen with
positive fluid wave, enlarged abdominal girth
Hepatomegaly right costal border in early
cirrhosis, later hard and small
Fetor hepaticus: fruity or musty breath odor
Asterixis (liver flap): coarse tremor of wrists
and fingers
94
Laboratory Assessment


Prolonged prothrombin time and INR
Serum elevation in:






Aspartate aminotransferase (AST)
Alanine aminotransferase (ALT)
Lactate dehydrogenase (LDH)
Indirect bilirubin, ammonia
Creatinine (hepatorenal syndrome)
Serum decrease in:


Albumin, Platelet count, Hemoglobin and hematocrit
White blood cell count
95
Diagnostic Procedures



Ultrasound
Percutaneous biopsy
Esophagogastro-duodenoscopy (EGD)
96
Liver Biopsy










Pre-procedure:
Labs: prothrombin time, CBC, platelet count
Fresh frozen plasma and/or platelets
Post-procedure:
Pressure to site, roll to right side for 1 hour
Hemoglobin and hematocrit
Chest x-ray to rule out pneumothorax
Ultrasound of liver to rule out hematoma
Report: ↓ BP, ↑ heart rate, respiratory distress, change
in level of consciousness
Report: increased pain, abdominal girth, weakness or
dizziness, bleeding
97
Esophagogastroduodenoscopy (EGD)

Pre-procedure:





NPO for 6-8 hours
IV access for conscious sedation
Remove dentures, assess gag reflex
Place in left lateral decubitus position
Post-procedure:



Frequent vital signs until conscious sedation worn off
Keep patient NPO until gag reflex returns
Monitor for: pain, bleeding, fever
98
Nutrition




High calorie, moderate fat
Ascites/edema – Low sodium to control fluid
retention, limit fluid intake if serum sodium is
low
High serum ammonia – limit protein
Vitamins/minerals – thiamine, folate, multiple
vitamins, fat-soluble vitamins (A,D,E,K),
magnesium
99
Fluids/Electrolytes





Monitor intake and output
Weigh patient daily
Daily electrolytes, BUN, creatinine, protein,
hematocrit
Monitor for signs of fluid retention
Give intravenous fluids and electrolytes as
indicated
100
Medication

Diuretics:

Spironolactone (Aldactone)Furosemide (Lasix)
Laxatives: lactulose (Cephulac)

Anti-infective agents:



Neomycin sulfate (aminoglycoside) Metronidazole
(Flagyl)
Alternative medications:

Silymarin (herb milk thistle), Adenosylmethione
(SAM-e)
101
Paracentesis
Patient preparation:







Informed consent
Weigh patient
Assess vital signs
Have patient void immediately prior to procedure
Supine, seated at edge of bed or in chair with feet
supported
Obtain vacuum bottle, paracentesis tray
May give 25% albumin intravenously
102
Post-Paracentesis






Bed rest
Monitor blood pressure for hypotension
Place patient supine, legs elevated if hypotensive
Send specimen to laboratory as ordered
Place dry dressing over puncture site – expect
some fluid leakage
Weigh patient
103
Esophageal Varices


Blood loss leading to shock occurs if these thinwalled varices burst.
Teach patient to avoid any activity that increases
abdominal pressure:



stooping
heavy lifting
vigorous physical exercise
104
Balloon Tamponade




Sengstaken-Blakemore tube
One larger balloon is inflated in the esophagus
to press on the varices
Smaller balloon is inflated in the stomach to
keep traction on the esophageal balloon.
A third lumen opens into the stomach to
aspirate blood and stomach contents.
105
Band Ligation

Endoscopic band ligation of varices:


Small “O” bands placed by physician around base of
varices to cut off blood supply.
The nurse may give an infusion of octreotide
before procedure to reduce blood flow
106
Sclerotherapy

Injection of an agent into the varices to occlude
their blood supply. Performed by an MD during
EGD.
107
Transjugular intrahepatic portalsystemic shunt (TIPS)

enlargement of portal vein with balloon
inflation and stent placed to maintain patency.
Photo Source: Courtesy of the University of Michigan
Health System,
http://www.med.umich.edu/1libr/aha/umliver09.htm
108
Shunts


Monitor patient for circulatory fluid overload:
increased blood pressure, crackles in lung bases.
Patient may need a diuretic.
Expect decreased ascites: decreased abdominal
girth, weight loss, increased urine output.
109
Hepatitis A (HAV)





Cause: Ingestion of fecal contaminants: water,
shellfish, food handlers, oral-anal sex
Incubation: 15-50 days
Signs: Mild, similar to gastrointestinal illness
Prevention: Wash hands, safe water supplies,
vaccination; immune globulin after exposure
Treatment: Bed rest, frequent small feedings of highprotein high-calorie foods, enteral feedings if unable to
eat; avoid alcohol & substances that affect liver function
110
Hepatitis B (HBV)





Cause: Blood from unprotected sex, sharing needles, accidental
needle sticks, unscreened blood transfusion, hemodialysis,
maternal-fetal
Incubation: 25-180 days
Signs: Fatigue, anorexia, nausea & vomiting, fever, RUQ pain,
rash, dark urine, light stool, joint pain, jaundice
Prevent: Screen donor blood, standard precautions with all
blood samples, disposable needles, lancets, needle-less IV
systems; vaccination of all newborns, high-risk persons
Passive immunity: hepatitis B Immune Globulin (HBIG) after
exposure (if not vaccinated); alpha interferon injections for
chronic infection; gradually increase activity
111
Hepatitis C (HCV)





Cause: Sharing needles (highest incidence), needle stick injury,
tattoos with dirty equipment, intranasal cocaine sharing
Incubation: 21-140 days (average 7 weeks)
Signs: gradual chronic inflammation of liver, eventual cirrhosis
(leading cause of liver transplants in U.S.), liver cancer possible
Prevent: Screen blood transfusions, sterile disposable
intravenous equipment; sterilize equipment. No vaccine
Treat: Interferon and ribavirin (Rebetol)
112
Pancreatic Disorders
Pancreatitis
Pancreatic Carcinoma
113
Pancreatitis





Inflammation characterized by release of its enzymes
into the pancreas causing hemorrhage and necrosis.
Risk Factors
Alcohol ingestion
Cholelithiasis
Post-Endoscopic Retrograde
Cholangiopancreatography (ERCP) complication
114
Manifestations







Abdominal pain localized in epigastrium – most
frequent symptom– relieved by fetal position or
bending forward
Nausea, vomiting, weight loss
Generalized jaundice
Gray-blue color around umbilicus (Cullen’s sign)
Gray-blue color to the flanks (Turner’s sign)
Respiratory compromise from abdominal pressure
Decreased breath sounds, especially at bases
115
Diagnosis - Lab








Increased serum amylase (nonspecific): remains elevated for 34 days
Increased lipase (more specific): remains elevated for 2 weeks
Elevated trypsin (most accurate)
Elevated bilirubin and alkaline phosphatase if concurrent biliary
dysfunction
Elevated alanine aminotransfersase (ALT) if biliary obstruction
Elevated glucose
Decreased calcium, magnesium if fat necrosis present
Elevated white blood cell count
116
Diagnosis: Radiography




Abdominal x-ray: gas-filled duodenum
(obstruction)
Chest x-ray: elevated left diaphragm, pleural
effusion
Computed tomography (CT) with contrast
Abdominal ultrasound
117
Collaborative Management






NPO, nasogastric drainage if vomiting with ileus
Pain relief
Comfort: bed rest, assist to fetal position if pain
acute
Intravenous fluids and electrolytes
Semi-fowlers position, frequent turning,
incentive spirometer
ERCP to remove gallstones and open sphincter
of Oddi
118
Monitor for complications:
Necrosis: sudden increase in pain
 Hemorrhagic shock
 Septic shock
 Respiratory failure

119
Pancreatic Carcinoma

Pain: boring pain in mid-back unrelated to position
or activity






Progressive and severe
More severe at night
Accentuated when lying supine
Relieved by sitting up and leaning forward
Jaundice with clay-colored stools, dark urine
Gastrointestinal: anorexia, nausea, vomiting, weight
loss, flatulence, ascites, glucose intolerance
120
Diagnosis




Elevated but nonspecific: amylase, lipase,
alkaline phosphatase, bilirubin
Elevated carcinoembryonic antigen (CEA) levels
in 80%-90%
Computed tomography (CT) confirms presence
of tumor versus cyst
ERCP with cystology of aspirate most definitive
diagnosis
121
Collaborative Management






Pain: high dose opioids, usually morphine or
hydromorphone (Dilaudid)
Chemotherapy
Radiation: shrinks tumor cells = pain relief
Biliary stent: if biliary drainage system is
obstructed
Laparoscopic procedures to palliate, debulk or
remove tumors
Whipple procedure (radical
pancreaticoduodenectomy) for extensive
metastasis
122
Whipple Procedure



GI drainage
Positioning
Pain



Watch! Sudden increased pain may be anastomosis
leak
Fluids and electrolytes
Nutrition
123
Biliary Disorders
Cholecystitis
Cholelithiasis
124
Cholecystitis/Cholelithiasis
Risk Factors








Excessive dietary cholesterol intake
Obesity
Increased age, female
Type I diabetes mellitus
Low-calorie or liquid protein diets
Alcohol abuse
Hemolytic blood disorders, such as Crohn’s disease
After gastric bypass surgery
125
Manifestations

Biliary colic: pain in right upper quadrant of the abdomen,
may radiate to back, right scapula, or shoulder










Abrupt onset – triggered by high-fat or high-volume meal
Severe and constant
Lasts 12-18 hours
Aggravated by movement, breathing
Anorexia, nausea, vomiting are common
Fevers and possibly chills
Jaundice & icterus
Pruritis
Clay-colored (light), fatty (steatorrhea) stools
Urine is dark and foamy
126
Diagnosis





Rebound tenderness in right upper quadrant
(Blumberg’s sign)
Pain increases with deep inspiration (Murphy’s sign)
while examiner pushes over gallbladder area (right
costal margin).
Direct bilirubin rises
Indirect bilirubin rises
Ultrasonography shows edema of gallbladder wall
surrounded by fluid.
127
Endoscopic Retrograde
Cholangiopancreatography (ERCP)
Contrast agent injected into the ducts
and x-rays are taken to evaluate their
caliber, length and course
128
Collaborative Management








Teach low-fat diet
If calculi are causing obstruction, give fat-soluble
vitamins
Ursodol (Actigall) or chenodial (Chenix)
Cholestyramine (Questran) for pruritis
Opiate analgesics
 Watch! morphine may cause biliary spasm and
constrict sphincter of Oddi (outlet).
Antispasmodic
Antibiotics if infection is suspected
Biliary catheter (T-tube)
129
Laparoscopic Cholecystectomy




Small puncture at umbilicus, carbon dioxide instilled
to lift abdominal wall.
Laparoscope inserted, attached to a monitor, and
abdominal organs are viewed.
Several small punctures are made to allow forceps
to manipulate the gallbladder, aspirate bile, crush
stones and remove all through the umbilical port.
Postoperative care: Pain from carbon dioxide
retention: Teach early ambulation to promote
absorption.
130
Open Cholecystectomy Postoperative
nursing care





Pain relief via patient-control analgesia (may be
meperidine instead of morphine if risk of sphincter
of Oddi) spasm.
Antiemetics – common postoperative nausea.
Incision and drain care
If drainage is large may give synthetic bile salts such
as dehydrocholic acid (Decholin) via NG tube
When patient is allowed to eat, clamp tube for 1-2
hours per surgeon’s order before and after meals
131
Home Care of T-tube









Report sudden increase in output
Inspect for signs of infection
Report change in drainage, abdominal pain, nausea
or vomiting
Clean and change dressing daily
Never irrigate, aspirate or clamp the drainage tube
without surgeon’s order
Prevent kinks, pulling tension or tangling of
tubing– keep drainage bag below tubing
Empty drainage bag
If ordered, clamp tube for 1-2 hours before and
after meals. Otherwise keep unclamped
Watch stools
132
Photo Acknowledgement:
All unmarked photos and clip art
contained in this module
were obtained from the
2003 Microsoft Office Clip Art Gallery.
133