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Nursing of Adult Patients with Medical & Surgical Conditions Gastrointestinal Accessory Organ Disorders Diagnostic Studies • Serum Bilirubin Test – Normal Values • • • • Direct bilirubin: 0.1 to 0.3 mg/dl Indirect bilirubin: 0.2 to 0.8 mg/dl Total bilirubin: 0.1 to 1.0 mg/dl Total bilirubin in newborns: 1 to 12 mg/dl – Rationale • Used to diagnose liver disease, biliary obstruction, erythroblastosis fetalis, and hemolytic anemia – Nursing Interventions • NPO Diagnostic Studies • Liver Enzyme Tests – Normal Values • AST (SGOT): 5-40 IU/L – elevated with MI, hepatitis, cirrhosis, hepatic necrosis, hepatic tumor, acute pancreatitis, acute renal failure, and acute hemolytic anemia • ALT (SGPT): 5-35 IU/L – elevated with hepatitis, cirrhosis, hepatic necrosis, hepatic tumors, and hepatotoxic drugs. • LDH: 45-90 U/L – elevated with MI, pulmonary infarction, hepatic disease, pacreatitis, hemolytic anemia, and skeletal muscle disease. Diagnostic Studies • Alkaline Phosphatase: 30-85 ImU/L – elevated in obstructive disorders of the biliary tract, hepatic tumors, cirrhosis, primary and metastatic tumors, hyperparathyroidism, metastatic tumor in bones and healing fractures • Gamma GT: 4-38 U/L – elevated with hepatitis, cirrhosis, hepatic tumors, hepatotoxic drugs, MI (4-10 days after), CHF, and alcohol ingestion – Rationale • Liver is storehouse for many enzymes • Injury or diseases affecting the liver will cause release of these enzymes into the bloodstream Diagnostic Studies • Serum Protein Test – Normal Values • • • • Total Protein: 6-8 g/dl Albumin: 3.2-4.5 g/dl Globulin: 2.3 to 3.4 g/dl Albumin globulin (A/G ratio): 1.2 to 2.2 g/dl – Rationale • The liver metabolizes protein, esp. albumin. If the liver is diseased it loses the ability to metabolize the albumin and the serum albumin level is decreased Diagnostic Studies • Oral Cholecystography (Gallbladder Series) – Rationale • Provides x-ray visualization of the gallbladder after ingestion of a radiopaque dye. • The following factors are necessary for adequate dye concentration: – Ingestion fo correct number of dye tablets – Adequate absorption of the dye from the GI tract; no vomiting or diarrhea – Abstinence from food the morning of the test – Patency of the cystic duct – Concentration of the cye within the gallbladder Diagnostic Studies – Nursing Interventions • Assess for allergies to iodine • Administer 6 Telepaque tablets orally, after the evening meal • NPO after midnight Diagnostic Studies • Intravenous Cholangiography (IV Cholangiogram) – Rationale • Radiographic dye is administered IV • Allows visualization of the hepatic and common bile ducts and also the gallbladder if the cystic duct is patent • Used to visualize stones, strictures, or tumors of the hepatic duct, common bile duct, and gallbladder. Diagnostic Studies • Operative Cholangiography – Rationale • Common bile duct is injected directly with radiopaque dye. • Visualization of stones or other obstructions during surgery to prevent unneccessary common bile duct exploration Diagnostic Studies • T-Tube Cholangiogram – Rationale • Demonstrates good flow of contrast into the duodenum • Diagnose retained ductal stones and/or leaks in ducts – Nursing Interventions • • • • T-tube to closed drainage system Cover site with sterile dressing, if t-tube removed Assess for allergies to iodine NPO after midnight Diagnostic Studies • Ultrasound of the Liver, Gallbladder, and Biliary System – Rationale • Visualization of deep structures by recording the reflections of ultrasonic waves directed in to the tissue – Nursing Interventions • NPO after midnight • Should be done before barium studies or after all barium has been expelled Diagnostic Studies • Gallbladder Scanning – Rationale • Injection of technetium 99 is given and scan is done to visualize the gallbladder and biliary tract • Used to diagnose acute cholecystitis – Nursing Interventions • NPO after midnight Diagnostic Studies • Liver Biopsy – Rationale • Needle is inserted through the abdominal wall into the liver to remove a piece of liver tissue • Used to diagnose cirrhosis, hepatitis, drug-related reactions, granuloma, and tumors – Nursing Interventions • Informed consent • NPO for 4-8 hours • Assess lab results for normal platelet count and prothrombin time Diagnostic Studies • After biopsy – Assess for s/s of bleeding – Vital signs every 15 min x 1hr, every 30 min x 4 hrs, then every 4 hrs – Assess for s/s of pneumothorax – Bed rest for 24 hrs Diagnostic Studies • Liver Scanning – Rationale • Radionuclide is given IV • Geiger counter is used to record the distribution of radioactive particles in the liver – Nursing Interventions • NPO after midnight Diagnostic Studies • Blood Ammonia – Normal Value • 15 to 110 micrograms/dl – Rationale • Ammonia is normally converted into urea and then excreted by the kidneys • Liver dysfunction or altered blood flow to the liver causes blood ammonia levels to rise and BUN (blood urea nitrogen) to decrease – Nursing Interventions • Notify lab if patient is currently taking Neomycin; can cause decreased ammonia levels Diagnostic Studies • Hepatitis Virus Studies – Rationale • Diagnose specific virus causing hepatitis – A, B, C, D, and E Diagnostic Studies • Serum Amylase Test – Normal Value • 25 to 125 U/L – Rationale • Damage to pancreas cells or obstruction to the pancreatic ductal flow will cause an outporing of this enzyme and absorption into the bloodstream • Levels will rise within 12 hours of onset of pancreatic disease. • Rapidly cleared by the kidneys; levels may return to normal within 48-72 hrs – Nursing Interventions • Note administration of any IV dextrose; can cause a falsenegative result Diagnostic Studies • Urine Amylase Test – Normal Value • 3-35 IU/hr – Rationale • Disorders affecting the pancreas will cause elevated amylase levels in the urine because the kidneys rapidly clear amylase • Levels remain elevated in the urine for 7-10 days • Used to diagnose pancreatitis in patients who have had symptoms for 3 days or longer Diagnostic Studies – Nursing Interventions • Urine collection may be 2 hr spot urine, 6 hr, 12 hr, or 24 hr collection. – Record exact time collection is begun – Discard first urine specimen – Collect all subsequent urine, including the last urine voided exactly 2, 6, 12, or 24 hrs after collection began – Urine should be kept on ice during collection period Diagnostic Studies • Ultrasound of Pancreas – Rationale • Provides diagnostic information with the use of ultrasonography of the pancreas • Used to diagnose carcinoma, pseudocyst, pancreatitis, and pancreatic abcess – Nursing Interventions • NPO for 8 hours before test • Gas or barium will interfere with sound wave transmission Diagnostic Studies • Computerized Tomography of the Abdomen – Rationale • Cross-sectional image • Used to diagnose inflammation, tumors, cysts, ascites, aneurysm, and cirrhosis of the liver – Nursing Interventions • NPO after midnight • Some patients may experience claustrophobia Diagnostic Studies • Endoscopic Retrograde Cholangiopancreatography of the Pancreatic Duct (ERCP) – Rationale • A fiberoptic duodenoscope is inserted through the oral pharynx, through the esophagus and stomach, and into the duodenum. Dye is injected for radiographic visualization of the CBD and pancreatic duct. • Used to diagnose obstructive jaundice, remove common bile duct stones, and place biliary and pancreatic duct stents to bypass obstructions Diagnostic Studies – Nursing Interventions • • • • NPO for 8 hours before test Informed consent Must remain still for 1-2 hours After procedure – NPO until gag reflex returns – Assess for abdominal pain, tenderness and guarding – Assess for s/s of pancreatitis • abd. pain, nausea, vomiting, and diminished or absent bowel sounds Cirrhosis • Etiology/Pathophysiology – Chronic, degenerative disease of the liver – Scar tissue restricts the flow of blood to the liver – Types of cirrhosis • Laennec’s cirrhosis – history of chronic ingestion of alcohol • Postnecrotic cirrhosis – viral hepatitis, exposure to hepatotoxins, or infection • Primary biliary cirrhosis – destruction of the bile ducts • Secondary biliary cirrhosis – chronic biliary tree obstruction (gallstones, tumor, etc.) Cirrhosis – Alteration of liver function • Reduced ability to metabolize albumin • Obstruction of portal vein • Increased pressure in the veins that drain the GI tract • Complications – Portal Hypertension • increased venous pressure in the portal circulation caused by compression or occlusion in the portal or hepatic vascular system – Ascites • accumulation of fluid and albumin in the peritoneal cavity • Esophageal Varicosities – veins in the upper part of the body distend, including the esophageal veins due to portal hypertension. They may rupture causing severe hemorrhage Cirrhosis • Hepatic Encephalopathy – Brain damage due to elevated ammonia levels – Inaapropriate behavior, disorientation, flapping hand tremors, twitching of the extremities, stupor, and coma Cirrhosis • Signs & Symptoms – Early stages • Abdominal pain • Liver is firm and easy to palpate – Late stages • dyspepsia • changes in bowel habits – constipation or diarrhea • Nausea and vomiting • gradual weight loss Cirrhosis • • • • • ascites enlarged spleen spider angiomas anemia bleeding tendencies – cannot absorb vitamin K, or produce clotting factors • • • • epistaxis purpura hematuria bleeding gums Cirrhosis • jaundice – yellow discoloration of the skin, mucous membranes and sclerae or the eyes – caused by abnormal amounts of bilirubin in the blood • mental disorientation Cirrhosis • Treatment – Eliminate the cause • alcohol, hepatotoxins, environmental exposure to harmful chemicals – Diet • • • • • • Well balanced High-calorie (2500 to 3000 cal/day) Moderate protein (75 g/day) Low fat Low sodium (1000 to 2000 mg/day) Supplemental vitamins and folic acid – Antiemetics Cirrhosis • Benadryl & Dramamine • Contraindicated: Vistaril, Compazine, and Atarax – Treatment of Complications • Ascites – – – – – – Bedrest Strict I&O Restrict fluids to 500 -1000 cc/day Restrict sodium to 1000-2000 mg/day Diuretics: Aldactone, Lasix, HCTZ Vitamin Supplements: Vitamin K, Vitamin C and folic acid – LeVeen Peritoneal-Jugular Shunt – Paracentesis LeVeen Peritoneal Jugular Shunt Paracentesis Cirrhosis • Ruptured Esophageal Varices – Maintain airway – Establish IV – Vasopressin drip to control bleeding • IV or directly into the superior vena cava – Sengstaken-Blakemore tube – Endoscopic sclerotherapy – Portacaval shunt • divert blood from the portal vein to the inferior vena cava – Blood transfusion Sengstaken-Blakemore Tube Cirrhosis • Hepatic Encephalopathy – Decrease protein in diet – Avoid drugs which are detoxified by the liver – Lactulose • Oral or retention enema • decreases the pH of the bowel which decreases the production of ammonia – Neomycin • inhibits protein synthesis in bacteria, therefore decreasing the production of ammonia Hepatitis • Etiology/Pathophysiology – Inflammation of the liver resulting from several types of viral agents or exposure to toxic substances – Hepatitis A • Most common • Incubation 10-40 days • Oral-fecal trasmission Hepatitis – Hepatitis B • Incubation 28-160 days • Transmission by contaminated serum; blood transfusion, contaminated needles, dialysis, or direct contact with infected body fluids – Hepatitis C • Incubation 2 weeks to 6 months (usually 6-9 weeks) • Transmitted through contaminated needles and blood transfusions – Hepatitis D • Coinfection with hepatitis B • Incubation 2-10 weeks Hepatitis – Hepatitis E • Fecal contamination of water • Rare in the U.S.; usually in developing countries • Incubation 15-64 days Hepatitis • Signs & Symptoms – – – – – – – – General malaise Aching muscles Photophobia Headaches Chills Abdominal pain Dyspepsia Nausea Hepatitis – – – – – – – – – Diarrhea Constipation Pruritus Hepatomegaly Enlarged lymph nodes Weight loss Jaundice Dark amber urine Clay colored stools Hepatitis • Treatment – Treat signs and symptoms – Small frequent meals • low-fat, high carbohydrate – IV fluids for dehydration • Vitamin C for healing • Vitamin B-complex for absorption of fat soluble vitamins • Vitamin K for coagulation – Avoid unnecessary medications, esp seditives Hepatitis – Gamma globulin or immune serum globulin • should be given to anyone exposed to Hepatitis A • may be given 2 weeks before and 1 week after onset of symptoms – Hepatitis B imune globulin (HBIG) • should be given to anyone exposed to Hepatitis B – Hepatitis B Vaccine • should be given to persons identified as high risk for developing Hepatitis B – healthcare personnel – high-risk lifestyle (drug users, homosexual men, prostitutes) – infants born to mothers who are Hepatitis B positive Liver Abscesses • Etiology/Pathophysiology – May be single of multiple – Abscess forms in the liver due to an invading bacteria Liver Abscesses • Signs & Symptoms – – – – – – Fever Chills Abdominal pain and tenderness in the RUQ Hepatomegaly Jaundice Anemia Liver Abscesses • Treatment – IV antibiotics – Percutaneous drainage of liver abscess – Open surgical drainage Cholecystitis & 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 Native American or white Obesity Pregnancy Diabetes Multiparous women Use of birth control Cholelithiasis Cholelithiasis Cholecystitis & Cholelithiasis • Signs & Symptoms – Indigestion after eating foods high in fat – Severe, colicky pain in the right upper quadrant • may radiate around the midtorso to the right scapular area – – – – – Anorexia Nausea & vomiting Flatulence Increased heart & respiratory rates Diaphoresis Cholecystitis & Cholelithiasis – – – – – Low grade fever Elevated WBC Mild jaundice Steatorrhea (fatty stool) Dark amber urine Cholecystitis & Cholelithiasis • Treatment – Mild attacks • • • • • Bedrest NG tube to suction NPO IV fluids Antispasmodic/Analgesic – Demerol: decreases incidence of spasms of the sphincter of Oddi • Antibiotics • Avoid spicy foods when allowed PO intake Cholecystitis & Cholelithiasis – Lithtripsy • A machine discharges a series of shock waves through water or a cushion that breaks the stone into fragments – Cholecystectomy (Removal of the gallbladder) • Laparoscopic – Oral liquids post-op – Outpatient or discharged next day – Resume moderate activity in 48-72 hrs • Open – – – – Jackson-Pratt drain T-tube NG tube Routine post-op care T-Tube Pancreatitis • Etiology/Pathophysiology – Inflammation of the pancreas • Acute or Chronic – Predisposing Factors • • • • Alcohol Trauma Infectious disease Certain drugs – Obstruction of the pancreatic duct may cause a rupture and enzymes digest the pancreas Pancreatitis Pancreatitis • Signs & Symptoms – – – – – – – – – – Abdominal pain Anorexia Nausea & vomiting Malaise Restlessness Low-grade fever Jaundice Weight loss Steatorrhea Tachycardia Pancreatitis • Treatment – – – – – NPO IV fluids NG tube Antiemetics Demerol 75 -100 mg q 3-4 hrs • Avoid morphine; causes spasms of the sphincter of Oddi – Anticholinergics – atropine or Pro-Banthine – Antacids or Tagamet (prevent ulcers) Pancreatitis – Hyperalimentation • may be required to maintain nutrition – Prevention • bland, low-fat, high-protein, high-carbohydrate diet • no alcohol or gastric stimulants (coffee) • may need oral hypoglycemic agents if destruction or the islets of Langerhans Cancer of the Pancreas • Etiology/Pathophysiology – Unknown – Risk factors • • • • • cigarette smoking exposure to chemical carcinogens diabetes mellitus pancreatitis diet high in meat, fat and coffee – May be metastisis form the lung, stomach, duodenum or CBD – May live only 4-8 months after diagnosis Cancer of the Pancreas Cancer of the Pancreas • Signs & Symptoms – – – – – – – – – Anorexia Fatigue Nausea Flatulence Change in stools Steady, dull aching pain in the epigastic area Weight loss Jaundice Onset of diabetes mellitus Cancer of the Pancreas • Treatment – Surgery • Whipple procedure – resection of the antrum of the stomach, duodenum, and part of the pancreas – anastomosis between the stomach, CBD, and pancreatic ducts and the jejunum • Total pancreatectomy with resection of parts of the GI tract – Chemotherapy – 5-FU and BCNU – Gemzar – Radiation Whipple Procedure