Download 10.Interventions for clients with liver, gallbladder and

Interventions for
clients with liver,
galdbladder and
pancreas disorders.
Clients
with
.
malnutrition and
obesity.
Liver disorders
Hepatitis
 1. Definition: inflammation of the liver
due to virus, exposure to alcohol, drugs,
toxins; may be acute or chronic in nature
 2. Pathophysiology: metabolic functions
and bile elimination functions of the liver
are disrupted by the inflammation of the
liver.
Hepatitis
 Widespread viral inflammation of liver
cells
 Hepatitis A
 Hepatitis B
 Hepatitis C
 Hepatitis D
 Hepatitis E
 Hepatitis F and G are uncommon
Hepatitis
Viral Hepatitis
 1. Types (causative agents)
a. Hepatitis A virus (HAV) Infectious hepatitis
 1. Transmission: fecal-oral route, often contaminated
foods, water or direct contact, blood transfusions,
contaminated equipment
 2. Contagious through stool up to 2 weeks before
symptoms occur; abrupt onset
 3. Benign, self limited; symptoms last up to 2
months
Hepatitis
 Prevention of Hepatitis A




Good handwashing
Good personal hygiene
Control and screening of food handlers
Passive immunization
 Incubation period :20-50 days (short
incubation period)
Hepatitis
 Incidence
 More common in fall and
winter months
 Usually found in children and
young adults
 Infectious for 3 weeks prior
and 1 week after developing
jaundice
 Clinical recovery 3-16 weeks
Hepatitis
Hepatitis B virus (HBV)
 1. Transmission:
 infected blood and body fluids,
 parenteral route with infusion
 ingestion or inhalation of the blood of an infected person
 Contaminated needles, syringes, dental instruments
 Oral or sexual contact
 High risk individuals include homosexual, IV drug
abusers, persons with multiple sexual partners, medical
workers
 2. Liver cells damaged by immune response; increased risk
for primary liver cancer; causes acute and chronic hepatitis,
fulminant hepatitis and carrier state
Hepatitis
Hepatitis C virus (HCV)
 1. Transmission: infected blood and body
fluids; injection drug use is primary factor
 2. Initial manifestations are mild, nonspecific
 3. Primary worldwide cause of chronic
hepatitis, cirrhosis, liver cancer
 4. Usual incubation period 7-8 weeks
Hepatitis
Hepatitis E virus (HEV)
 1. Transmission: fecal-oral route,
contaminated water supplies in
developing nations; rare in U.S.
 2. Affects young adults; fulminant in
pregnant women
Clinical Manifestations










Abdominal pain
Changes in skin or eye color
Arthralgia (joint pain)
Myalgia (muscle pain)
Diarrhea/constipation
Fever
Lethargy
Malaise
Nausea/vomiting
Pruritus
Nonsurgical Management




Physical rest
Psychological rest
Diet therapy
Drug therapy includes:
 Antiemetics
 Antiviral medications
 Immunomodulators
Fatty Liver
(Steatohepatitis)
 Fatty liver is caused by the
accumulation of fats in and around the
hepatic cells.
 Causes include:
 Diabetes mellitus
 Obesity
 Elevated lipid profile
 Many clients are asymptomatic
Hepatic Abscess
 Liver invaded by bacteria or protozoa
causing abscess
 Pyrogenic liver abscess; amebic
hepatic abscess
 Treatment usually involves:
 Drainage with ultrasound guidance
 Antibiotic therapy
Liver Trauma
 The liver is the most common organ injured
in clients with penetrating trauma of the
abdomen, such as gunshot wounds and
stab wounds.
 Clinical manifestations include abdominal
tenderness, distention, guarding, rigidity.
 Treatment involves surgery, multiple blood
products.
Cirrhosis
 Cirrhosis is extensive scarring of the liver,
usually caused by a chronic irreversible
reaction to hepatic inflammation and
necrosis.
 Complications depend on the amount of
damage sustained by the liver.
 In compensated cirrhosis, liver has
significant scarring but performs essential
functions without causing significant
symptoms.
Complications






Portal hypertension
Ascites
Bleeding esophageal varices
Coagulation defects
Jaundice
Portal-systemic encephalopathy with
hepatic coma
 Hepatorenal syndrome
 Spontaneous bacterial peritonitis
Etiology
 Known causes of liver disease include:








Alcohol
Viral hepatitis
Autoimmune hepatitis
Steatohepatitis
Drugs and toxins
Biliary disease
Metabolic/genetic causes
Cardiovascular disease
Clinical Manifestations
 In early stages, signs of liver disease
include:





Fatigue
Significant change in weight
Gastrointestinal symptoms
Abdominal pain and liver tenderness
Pruritus
Clinical Manifestations
 In late stages, the signs vary:







Jaundice and icterus
Dry skin
Rashes
Petechiae, or ecchymoses (lesions)
Warm, bright red palms of the hands
Spider angiomas
Peripheral dependent edema of the
extremities and sacrum
Abdominal Assessment
 Massive ascites
 Umbilicus protrusion
 Caput medusae (dilated abdominal
veins)
 Hepatomegaly (liver enlargement
Other Physical
Assessments
 Assess nasogastric drainage, vomitus, and
stool for presence of blood
 Fetor hepaticus (breath odor)
 Amenorrhea
 Gynecomastia, testicular atrophy,
impotence
 Bruising, petechiae, enlarged spleen
 Neurologic changes
 Asterixis
Laboratory Assessment
 Aminotransferase serum levels and
lactate dehydrogenase may be
elevated.
 Alkaline phosphatase levels may
increase.
 Total serum bilirubin and urobilinogen
levels may rise.
 Total serum protein and albumin
levels decrease.
Laboratory Assessment
(Continued)
 Prothrombin time prolonged; platelet
count low
 Decreased hemoglobin and
hematocrit values and white blood cell
count
 Elevated ammonia levels
 Serum creatinine level possibly
elevated
Surgical Interventions
 Peritoneovenous shunt
 Portocaval shunt
 Transjugular intrahepatic
portosystemic shunt
Cancer of the Liver
 One of the most common tumors in
the world
 Most common complaint: abdominal
discomfort
 Treatment includes:
 Chemotherapy
 Surgery
Liver Transplantation
 Used in the treatment of end-stage
liver disease, primary malignant
neoplasm of the liver
 Donor livers obtained primarily from
trauma victims who have not had liver
damage
 Donor liver transported to the surgery
center in a cooled saline solution that
preserves the organ for up to 8 hours
Complications








Acute, chronic graft rejection
Infection
Hemorrhage
Hepatic artery thrombosis
Fluid and electrolyte imbalances
Pulmonary atelectasis
Acute renal failure
Psychological maladjustment
Acute Cholecystitis
 Acute cholecystitis is the inflammation of
the gallbladder.
 Cholelithiasis (gallstones) usually
accompanies cholecystitis.
 Acalculous cholecystitis inflammation can
occur in the absence of gallstones.
 Calculous cholecystitis is the obstruction of
the cystic duct by a stone, which creates an
inflammatory response.
Chronic Cholecystitis
 Repeated episodes of cystic duct
obstruction result in chronic
inflammation
 Pancreatitis, cholangitis
 Jaundice
 Icterus
 Obstructive jaundice
 Pruritus
Clinical Manifestations
 Flatulence, dyspepsia, eructation,
anorexia, nausea and vomiting,
abdominal pain
 Biliary colic
 Murphy’s sign
 Blumberg’s sign
 Rebound tenderness
 Steatorrhea
Nonsurgical Management
 Diet therapy: low-fat diet, fat-soluble
vitamins, bile salts
 Drug therapy: opioid analgesia with
meperidine hydrochloride,
antispasmodic or anticholinergic
drugs, antiemetic
 Percutaneous transhepatic biliary
catheter insertion
Surgical Management




Laparoscopic cholecystectomy
Standard preoperative care
Operative procedure
Postoperative care
 Free air pain result of carbon dioxide
retention in the abdomen
 Ambulation
 Return to activities in 1 to 3 weeks
Traditional
Cholecystectomy
 Standard preoperative care
 Operative procedure
 Postoperative care
 Meperidine hydrochloride via patient-controlled
analgesia pump
 Antiemetics
 Wound care
 Care of the T-tube
 Nothing by mouth
 Diet therapy
Cancer of the Gallbladder
 Anorexia, weight loss, nausea,
vomiting, general malaise, jaundice,
hepatosplenomegaly, chronic,
progressively severe epigastric or
right upper quadrant pain
 Poor prognosis
 Surgery, radiation, chemotherapy
Acute Pancreatitis
 Serious and possibly life-threatening
inflammatory process of the pancreas
 Necrotizing hemorrhagic pancreatitis
 Lipolysis
 Proteolysis
 Necrosis of blood vessels
 Inflammation
 Theories of enzyme activation
Complications of Acute
Pancreatitis






Hypovolemia
Hemorrhage
Acute renal failure
Paralytic ileus
Hypovolemic or septic shock
Pleural effusion, respiratory distress
syndrome,pneumonia
 Multisystem organ failure
 Disseminated intravascular coagulation
 Diabetes mellitus
Clinical Manifestations





Generalized jaundice
Cullen’s sign
Turner’s sign
Bowel sounds
Abdominal tenderness, rigidity,
guarding
 Pancreatic ascites
 Significant changes in vital signs
Surgical Management
 Preoperative care: NG tube may be
inserted
 Operative procedures
 Postoperative care
 Monitor drainage tubes and record
output from drain.
 Provide meticulous skin care and
dressing changes.
 Maintain skin integrity.
Chronic Pancreatitis
 Progressive destructive disease of the
pancreas, characterized by remissions
and exacerbations
 Nonsurgical management includes:





Drug therapy
Analgesic administration
Enzyme replacement
Insulin therapy
Diet therapy
Pancreatic Abscess
 Most serious complication of
pancreatitis; always fatal if untreated
 High fever
 Blood cultures
 Drainage via the percutaneous
method or laparoscopy
 Antibiotic treatment alone does not
resolve abscess
Pancreatic Carcinoma
 Nonsurgical management
 Drug therapy
 Radiation therapy
 Biliary stent insertion
Surgical Management
 Preoperative care
 NG tube may be inserted
 TPN typically begun
 Operative procedure may include Whipple
procedure
 Postoperative care





Observe for complications
Gastrointestinal drainage monitoring
Positioning
Fluid and electrolyte assessment
Glucose monitoring
Nutritional Standards to
Promote Health
 Dietary recommendations, food guide
pyramids for adequate nutrition
 Nutritional assessment includes:




Diet history
Anthropometric measurements
Measurement of height and weight
Assessment of body fat (body mass
index)
Malnutrition
 Protein-calorie malnutrition
 Marasmus calorie malnutrition, in
which body fat and protein are
wasted, serum proteins are often
preserved
 Kwashiorkor
 Marasmic-kwashiorkor
Laboratory Assessment




Hematology
Protein studies
Serum cholesterol
Other laboratory tests
Imbalanced Nutrition: Less
Than Body Requirements
 Interventions include:
 Drug therapy
 Partial enteral nutrition
 Total enteral nutrition
 Candidates for total enteral nutrition
Enteral Nutrition
 Types of enteral products for nutrients
 Methods of administration of total
enteral nutrition
 Types of tubes
 Types of feedings
 Complications of total enteral
nutrition:
 Aspiration, fluid excess, increased
osmolarity, dehydration, electrolyte
imbalances
Parenteral Nutrition
 Partial parenteral nutrition
 Total parenteral nutrition
 Complications include:




Fluid imbalances
Electrolyte imbalances
Glucose imbalances
Infection
Obesity
 Overweight: increase in body weight
for height compared to standard
 Obesity: at least 20% above upper
limit of normal range for ideal body
weight
 Morbid obesity: severe negative effect
on health
Obesity Complications







Diabetes mellitus
Hypertension
Hyperlipidemia
CAD
Obstructive sleep apnea
Obesity hypoventilation syndrome
Depression and other mental
health/behavioral health problems
Obesity Complications






Urinary incontinence
Cholelithiasis
Chronic back pain
Early osteoarthritis
Decreased wound healing
Increased susceptibility to infection
Obesity and Health
Promotion
 Health promotion/illness prevention
 Teach the potential consequences and
complications.
 Teach the importance of eating a healthy diet.
 Teach that foods eaten away from home tend to
be higher in fat, cholesterol, and salt, and lower
in calcium.
 Reinforce need for regular moderate activity for
at least 30 min per day.
 Educate regarding diet and activity for children
and adolescents, and continuing throughout
adulthood.
Nonsurgical Management
 Fasting
 Very low-calorie diets of 200 to 800 calories
per day
 Balanced and unbalanced low-energy diets
 Novelty diets
 Diet therapy
 Exercise program
 Drug therapy
 Complementary and alternative therapies
and treatments
Surgical Management





Liposuction
Panniculectomy
Bariatric surgery
Preoperative care
Operative procedures




Vertical banded gastroplasty
Circumgastric banding
Gastric bypass
Roux-en-Y gastric bypass
Postoperative Care





Analgesia
Skin care
Nasogastric tube placement
Diet
Prevention of postoperative
complications
 Observe dumping syndrome signs
such as tachycardia, nausea, diarrhea,
and abdominal cramping