Download Chapter 30

Medical-Surgical Nursing:
Concepts & Practice
3rd edition
Chapter 30
Care of Patients with Disorders of the Liver,
Gallbladder, and Pancreas
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Theory Objectives
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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.
Devise appropriate nursing interventions for the
patient with cirrhosis and ascites.
Indicate potential causes of liver failure.
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Theory Objectives (Cont.)
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Differentiate the signs and symptoms of acute
and chronic liver failure.
Discuss the criteria used for selection of liver
transplantation recipients.
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.
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Clinical Practice Objectives
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Perform preoperative teaching for a patient
who is to undergo laparoscopic
cholecystectomy.
Review a nursing care plan, including
psychosocial concerns, for the patient who
has hepatitis with jaundice.
Implement a discharge teaching plan for the
patient who has been in the hospital with a
flare-up of chronic pancreatitis.
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Cholelithiasis (gallstones) and
Cholecystitis(Inflammation of Gallbladder)
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Etiology
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Ethnic predisposition to gallstones (Native
Americans and Hispanic Americans) high
cholesterol diets
Pathophysiology – stones may obstruct bile
flow
Signs and symptoms
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None to severe and unbearable pain
N&V, fever, leukocytosis, jaundice
Unbearable upper right quadrant pain (bilary colic)
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Gallstones – page 695
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Cholelithiasis and Cholecystitis
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Diagnosis
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Ultrasonography of gallbladder and biliary tract
Computed tomography (CT)
Endoscopic retrograde cholangiopancreatography
(ERCP)
Cholescintigraphy (hepatoiminodiacetic acid
[HIDA] scan)
Liver function tests and WBC elevation and
sedimentation rate
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Cholelithiasis and Cholecystitis
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Treatment
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Low Fat Diet, weight loss, restrict alcohol intake,
small meals, oral medications that reduce
gallstones
Correction of bile obstruction by ERCP to remove
stones
Antibiotics only if peritonitis is present
Post-cholecystectomy diet
Surgery – U.S 90% laparoscopic
Complications – internal bleeding, abdominal
rigidity
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gallstones
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Postoperative Laparoscopic
Cholecystectomy
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Remove the bandages from the puncture
sites the day after surgery and shower.
Report the following signs and symptoms if
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 because these signs
may indicate obstruction of the flow of bile.
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Postoperative Laparoscopic
Cholecystectomy (Cont.)
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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.
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Gallbladder Disease Cholecystitis
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Nursing Management for Gallbladder
Surgery
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Preoperative care – NPO, antiemetics for
nausea or NG tube, IV fluids
Postoperative care – Semi-Fowlers, deep
breathing and coughing
Caring for a T-tube – patient may have tubes
or drains if continuing drainage is expected.
Dressing absorb. Change frequently. If fresh
blood appears, contact surgeon. Stool
should be brown (bile), if light color bile is
obstructed
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Hepatitis
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Etiology and pathophysiology
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Types of viral hepatitis – page 698 Table 30-2
Liver cells are damaged
Hep B and C are the most serious forms of
hepatitis, often progressing to chronic hepatitis,
liver cancer and death
Signs and symptoms – depend on the type of
hepatitis – see page 699
Diagnosis – hx, physical and labwork (table
30-3 pg 700)
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Hepatitis
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Treatment- rest to help the liver to
regenerate, small meals, Zofran for nausea,
antivirals medications,
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HEPATITIS IS AN OCCUPATIONAL
HAZARD FOR ALL PEOLE WHO HAVE
DIRECT CONTACT WITH PATIENTS.
STANDARD PRECAUTIONS MUST BE
OBSERVED AT ALL TIMES.
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Treatment of Hepatitis
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There is no specific treatment for acute viral
hepatitis.
Nondrug measures include a well-balanced
diet and rest and avoiding hepatotoxic
substances, including alcohol and certain
medications.
Active and passive immunity
Antiviral therapy
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Expected Outcomes
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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.
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Expected Outcomes (Cont.)
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Patient will verbalize knowledge of disease
process and self-care within 2 days.
Patient will engage in appropriate diversional
activities during convalescence.
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Nursing Interventions
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Monitor progress.
Prevent the spread of infection.
Patient and family teaching—proper handling
of body secretions, proper hand hygiene, and
limiting contact
Psychological support
Ensure adequate nutrition
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Cirrhosis- Chronic Disease of the Liver
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Etiology 
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Postnecrotic cirrhosis – viral hepatitis, toxic
substances, parasites or infection
Laënnec’s cirrhosis or portal cirrhosis - alcohol
Biliary cirrhosis – chronic biliary obstruction
Cardiac cirrhosis – right sided heart failure
ALCOHOLISM CAUSES DEPOSITION OF FAT
IN THE LIVER CELLS. THIS IS REVERSABLE IF
ALCOHOL CONSUMPTION IS HALTED
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Cirrhosis (Cont.)
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Diagnosis
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Liver biopsy
Liver function studies
CT and liver scan
Magnetic resonance cholangiopancreatography
Treatment—stopping the liver damage and
restoring the liver’s functions
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Signs and Symptoms
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Subjective symptoms
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Fatigue
Weakness
Headache
Anorexia
Indigestion
Abdominal pain
Nausea
Vomiting
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Signs and Symptoms (Cont.)
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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
(redness of palms)
Caput medusa (blue varicose veins around
umbilicus)
Bleeding and bruising, urine dark, jaundice
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Signs and Symptoms (Cont.)
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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.
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Signs and Symptoms (Cont.)
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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.
Elevations in liver enzymes usually do not
occur until 65% of liver function is gone.
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Signs and Symptoms of Cirrhosis
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Relationship of Systemic Portal
Hypertension and Ascites in Cirrhosis
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Nursing Management of Cirrhosis
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Assessment
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Assess for safety issues
Laboratory tests
Alcohol withdrawal
Nursing diagnosis
Planning and implementation
Evaluation
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Complications of Cirrhosis
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Esophageal varices – engorged veins from
portal congestion and hypertension, if vein
walls rupture, massive bleeding
Encephalopathy
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Delirium, convulsions, asterixis (tremors), and
coma
Fetor hepaticus (breath with a sweet, fecal odor)
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Treatment for Esophageal Varices –
page 711
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Liver Transplantation
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Legal and ethical considerations
Nursing management
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Care of drains
Immunosuppressants
Liver function monitoring
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Cancer of the Liver
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Etiology – usually metastatic
Pathophysiology – cirrhosis or hepatitis b or c
increase the risk, inflammation of normal liver
cells
Signs and symptoms – right upper quadrant
pain, fatigue, weight loss
Diagnosis - labwork, biopsy
Treatment – radiation and chemotherapy
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Liver cancer
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Acute Pancreatitis
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Etiology – alcoholism, trauma, viral infections
Pathophysiology – inflammation/damage
caused by the escape of pancreatic digestive
enzymes
Signs and symptoms- abdominal pain left upper
quadrant, eating makes the pain worse
Diagnosis –symptoms, ultrasound, CT, labwork
Treatment – pain management, fluids,
nutritional support
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Chronic Pancreatitis
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Etiology and pathophysiology – repeated bouts
of inflammation causes progressive fibrosis of
the gland, stricture of the ducts and eventual
calcification
Signs and symptoms – abdominal pain,
malabsorption with weight loss
Diagnosis
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Determination of bicarbonate concentration and
output in the duodenum after stimulation with
secretin is the definitive test for chronic pancreatitis.
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Chronic Pancreatitis (Cont.)
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Treatment and Nursing management
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Pain management
Complications, including diabetes mellitus
Avoid alcohol.
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Chronic Pancreatitis
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Cancer of the Pancreas
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Signs and symptoms epigastric pain and weight
loss. High incidence of clot formation
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Deep vein thrombosis
Diagnosis
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Ultrasonography, imaging techniques, and fine-needle
biopsy
Elevated carcinoembryonic antigen levels elevated 80
to 90%
Serum beta-human chorionic gonadotropin and
carbohydrate antigen (CA) 72-4
Tumor markers CA 19-9 and CA 242
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Cancer of the Pancreas (Cont.)
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Treatment
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Keep the patient comfortable.
Treat or prevent malnutrition.
Surgical treatment, including Whipple procedure
( head of pancreas, the gallbladder, the duodenum,
part of the jejunum and all or part of the stomach are
removed), or radical pancreaticoduodenectomy
Other treatments – ablation, microwave therapy
Nursing management – manage pain (page 716)
Community care – promote immunizations
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