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NUR 201 Week 10 > Biliary Disorders > Flashcards

Biliary Disorders Flashcards

- Cholelithiasis - Cholecystitis

1
Q

?

Is the most common disorder of the biliary system

Stones in the gallbladder

A

Cholelithiasis

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2
Q

?

Is inflammation of the gallbladder wall

Usually assoc w/cholelithiasis & occurs together but a person can have cholelithiasis w/o ___

May be present acutely or chronically

A

Cholecystitis

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3
Q

Gallbladder Disease

  • Common health problem
A

Risk factors

> Female
Multiparity
Age older than 40 yrs
Estrogen therapy; oral contraceptive use
Sedentary lifestyle
Genetics/ethnicity
Obesity [causes inc secretion of cholesterol in bile]

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4
Q

Cholelithiasis

  • Cause of gallstones unknown
  • Develops when balance that keeps cholesterol, bile salts, & calcium in solution is altered, leading to precipitation
    > i.e., d/t infection & disturbances in metabolism of cholesterol
A
  • Bile secreted by liver is supersaturated w/cholesterol (lithogenic bile)

> Other components of bile that precipitate into stones are bile salts, bilirubin, calcium, & protein
Mixed cholesterol stones, which’re predominantly cholesterol, are the most common gallstones

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5
Q
  • Stasis of bile > supersaturation & changes in composition of bile (biliary sludge)
  • Immobility, pregnancy, & inflammatory or obstructive lesions of biliary system ↓ bile flow
A
  • Stones may remain in GB or may migrate to cystic or CBD
  • Cause pain as they pass through ducts
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6
Q

Cholecystitis

  • Most commonly assoc w/obstruction from gallstones or biliary sludge

___ cholecystitis [in the absence of obstruction]
> Older adults & critically ill
> Prolonged immobility, fasting, prolonged parenteral nutrition, diabetes
> Bacteria or chemical irritants
> Adhesions, neoplasms, anesthesia, opioids

A

acalculous (cholecystitis)

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7
Q

Cholecystitis - Inflammation

  • Confined to mucous lining or entire wall
  • GB is edematous and hyperemic & may be distended w/bile or pus
  • Cystic duct may become occluded
  • Scarring & fibrosis after attack
A
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8
Q

Clinical Manifestations

  • Vary from severe to none at all
A
  • Pain more severe when stone moving or obstructing
    > Steady, excruciating
    > Tachycardia, diaphoresis, prostration
    > May be referred to shoulder/scapula
    > Residual tenderness in RUQ
    > Occurs 3-6 hrs after high-fat meal or when pt lies down
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9
Q

When total obstruction occurs:

> Dark amber urine
Clay-colored stools
Pruritus
Intolerance to fatty foods
Bleeding tendencies
Steatorrhea

A
  • If the CBD is obstructed, no bilirubin will reach the SI to be converted to urobilinogen
  • Thus bilirubin will be excreted by the kidneys instead, causing dark amber to brown urine
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10
Q
  • In addition to pain

> Indigestion
Fever, chills
Jaundice
Pain, tenderness RUQ
- Referred to right shoulder, scapula

A

> N/V
Restlessness
Diaphoresis

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11
Q
  • Inflammation
    > Leukocytosis, fever
  • Physical exam findings
    > RUQ or epigastrium tenderness
    > Abd rigidity
A

Chronic cholecystitis Manifestations

> Fat intolerance
Dyspepsia
Heartburn
Flatulence

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12
Q

Cholelithiasis & Cholecystitis - Complications

  • Gangrenous cholecystitis
  • Subphrenic abscess
  • Pancreatitis
  • Cholangitis [inflammation of biliary ducts]
A
  • Biliary cirrhosis
  • Fistulas
  • GB rupture > (bile) peritonitis
  • Choledocholithiasis (stone in the CBD > obstruction)
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13
Q

In older pts & those w/diabetes, gangrenous cholecystitis & bile peritonitis are the most common complications of cholecystitis

A
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14
Q

Diagnostic Studies

  • US (to diagnose gallstones; useful for pts w/jaundice & those allergic to contrast medium)
  • ERCP
    > Visualize GB, cystic duct, common hepatic duct, & CBD
    > Bile sent for culture
A
  • Percutaneous transhepatic cholangiography
    > Is the insertion of a needle directly into the GB duct, followed by injection of contrast materials
    > Generally done >US indicates a bile duct blockage
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15
Q

Laboratory tests

↑ WBC count (d/t inflammation)

↑ serum bilirubin (direct/indirect) & urinary bilirubin [if an obstructive process present]

A

↑ liver enzymes (alkaline phosphatase, ALT, AST)

↑ serum amylase (if pancreatic involvement)

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16
Q
  • Treatment dependent on stage of disease
A
  • Oral dissolution therapy [to dissolve stones]
    > Ursodeoxycholic acid (ursodiol) [Actigall]
    > Chenodeoxycholic acid (chenodiol)
  • Gallstones aren’t usually treated w/rx’s, b/c high use & success of laparoscopic cholecystectomy
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17
Q

ERCP w/sphincterotomy (papillotomy)

  • Visualization
  • Dilation (balloon sphincteroplasty)
  • Placement of stents; sphincterotomy
  • Open sphincter of Oddi, if needed
  • Endoscope passed to duodenum
  • Stones removed w/basket or allowed to pass in stool
A
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18
Q

Endoscopic Sphincterotomy

  • An endoscope is advanced through the mouth & stomach until its tip sits in the duodenum opposite the CBD
A
  • After widening the duct mouth by incising the sphincter muscle, the physician advances a basket attachment into the duct & snags the stone
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19
Q

?

This is an alternate treatment used when stones cannot be removed by endoscopic approaches

A

Extracorporeal shock-wave lithotripsy (ESWL)

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20
Q

ESWL

  • A lithotriptor produces high-energy shock waves to disintegrate gallstones once they have been located by US
  • Usually takes 1-2 hrs for stones to disintegrate
A
  • After they’re broken up, the fragments pass through the CBD & into the SI
  • Usually ESWL & oral dissolution therapy are used together
21
Q
  • Control possible infection
    > Antibiotic treatment

! Maintenance of F&E balance

  • NG tube for severe N/V
  • Cholecystostomy (to drain purulent material from obstructed GB)
A
  • Opioids for pain control
  • Anticholinergics
    > Decrease GI secretions
    > Counteract smooth muscle spasms
22
Q

?

  • Treatment of choice for symptomatic cholelithiasis
  • Removal of GB through 1 to 4 puncture sites
  • Minimal postop pain
  • Resume normal activities, inc work, within 1 wk
  • Few complications (main inj is to CBD)
A

Laparoscopic cholecystectomy

23
Q

Contraindications to laparoscopic cholecystectomy include

> Peritonitis
Cholangitis
Gangrene or perforation of the GB
Portal HTN
Serious bleeding disorders

A
24
Q

Open (incisional) cholecystectomy

  • Removal of GB through right subcostal incision
A
  • T-tube inserted into CBD
    > Ensures patency of duct
    > Allows excess bile to drain
25
Q

Transhepatic Biliary Catheter

  • Preoperative or palliative
    > When endoscopic drainage fails
  • Inserted percutaneously & attached to drainage bag
A
  • Replace fluids lost w/electrolyte-rich drinks
  • Skin care important
26
Q

Drug Therapy - Most common

  • Analgesics (morphine)
    > Initially for pain management
  • Anticholinergics [antispasmodics] (atropine)
    > To relax smooth muscle & dec ductal tone
A
  • Fat-soluble vitamins (A, D, E, K)
    > For those w/chronic GB dz or any biliary tract obstruction
  • Bile salts
    > To facilitate digestion & vitamin absorption
27
Q

___ may be given for pruritus

> Given in powdered form, mixed w/milk or juice
Monitor for side effects (n/v/d or constipation, skin reactions)
Check drug-to-drug interactions (b/c it can bind w/other rx’s)

A

cholestyramine

28
Q

?

This is a resin that binds bile salts in the intestine, increasing their excretion in the feces

A

cholestyramine

29
Q

Nutritional Therapy

  • Small, frequent meals w/some fat
  • Diet low in saturated fat
  • High in fiber & calcium
A
  • Reduced-calorie diet if pt is obese
  • Avoidance of rapid wt loss (b/c it can promote gallstone formation)
30
Q

After laparoscopic cholecystectomy
> liquids 1st day
> light meals for several days

A

After incisional cholecystectomy
> liquids to regular diet after return of bowel sounds
> may need to restrict fats for 4-6 wks [will depend on pt’s tolerance of fats]

31
Q

Nursing Management - Subjective Data

Past medical history - obesity, multiparity, infection, cancer, extensive fasting, pregnancy

Medication use - estrogen, oral contraceptives

Surgical hx - prev abd surgery

A

Health perception-health management - positive family hx, sedentary lifestyle

Nutritional-metabolic - wt loss or anorexia, indigestion or fat intolerance, N/V or dyspepsia, chills

32
Q

Elimination - clay-colored stools, steatorrhea, flatulence, dark urine

Cognitive-perceptual - mod to severe pain in RUQ that may radiate to the back or scapula; pruritus

A

Objective Data

  • Fever, restlessness; jaundice/icteric sclera, diaphoresis; tachypnea, splinting during respirations
  • Tachycardia; palpable GB, abd guarding & distention
33
Q

Abnormal diagnostic findings

↑ serum liver enzymes, alkaline phosphatase, bilirubin

Absence of urobilinogen in urine

A

↑ urinary bilirubin

Leukocytosis

Abn GB US findings

34
Q

Nursing Diagnoses

  • Acute pain r/t surgical procedure
  • Ineffective health management r/t lack of knowledge of diet & postop management
A

Overall Goals

  1. Relief of pain & discomfort
  2. No complications postoperatively
  3. No recurrent attacks of cholecystitis or cholelithiasis
35
Q

Health Promotion

  • Screen for predisposing factors
  • Teaching for at-risk ethnic groups (Native Americans)
  • Early detection of chronic cholecystitis
    > Manage w/low-fat diet
A

Acute Care - Nursing Goals

  • Treating pain
  • Relieve N/V
  • Provide comfort & emotional support
  • Maintain F&E balance & nutrition
  • Accurate assessments
  • Monitor for complications
36
Q
  • Pain management
  • Administering rx’s
  • Assess effectiveness
  • Comfort measures
  • Clean bed; positioning; oral care
A
  • Manage N/V
  • NG tube, gastric decompression
    > Oral hygiene, care of nares
    > Accurate I&O
    > Maintenance of suction
  • Antiemetics
  • Comfort measures (i.e., freq mouth rinses; remove vomitus from view)
37
Q
  • Pruritus relief measures
  • Antihistamines
  • Baking soda or Alpha Keri baths
  • Lotions (i.e., calamine)
  • Soft linen
  • Control of temperature
  • Short, clean nails
  • Scratch w/knuckles rather than nails
A
  • Monitor for complications
  • Obstruction
  • Bleeding
  • Infection
38
Q

Obstruction signs of ducts by stones

  • Jaundice
  • Clay-colored stools
  • Dark, foamy urine
  • Steatorrhea
  • Fever
  • Inc WBC count
A
  • Bleeding from dec prothrombin production by liver
  • Look @ the mucous membranes of the mouth, nose, gingivae, & injection sites
    > Use a small-gauge needle & apply pressure after injection
  • Monitor VS to assess for infection
39
Q

?

A temperature elevation w/chills & jaundice may indicate which condition?

A

choledocholithiasis

40
Q

Care of the pt >ERCP w/sphincterotomy; ERCP w/papillotomy

> Assess for pancreatitis, perforation, infection, & bleeding
Monitor VS
Abd pain, fever, inc amylase & lipase may indicate pancreatitis

A

> Pt to be on bedrest for several hrs & on NPO status until gag reflex returns

> Teach need for f/u if stent is to be removed or changed

41
Q

Postop Care: Laparoscopic cholescystectomy

  • Monitor for complications
  • Pt comfort
    > Referred pain to shoulder pain from CO2
    > Sims’ position
    > Deep breathing, ambulation, analgesia
A
  • Clear liquids
  • Discharged same day
42
Q

Postop Care: Laparoscopic cholecystectomy

  • Monitor for complications (i.e., bleeding)
  • Pt comfort
    > Referred pain to shoulder from CO2 that’s used to inflate abd cavity during surgery (common!; CO2 can irritate the phrenic nerve & diaphragm, causing some difficulty in breathing)
  • Place in Sims’ position (left side w/right knee flexed)
    > Deep breathing, ambulation, analgesia
A
  • Manage pain (NSAIDs, codeine)
  • Clear liquids
  • Discharged same day
43
Q

Postop Care: Incisional cholecystectomy

  • Maintain adequate ventilation
  • Prevent respiratory complications
  • General postop nursing care
A
  • Maintain drainage tubes (T-tube, Penrose, JP tube), if present
    > Use a sterile pouching system to protect the skin
  • Replace F&E
44
Q

Ambulatory Care

  • Dietary teaching
    > Low-fat diet
    > Wt reduction if needed
    > Fat-soluble vitamin supplements
A
  • Teach what to report
    > Signs of obstruction include stool & urine changes; jaundice; pruritus
  • Follow-up care
45
Q

Ambulatory Care - Laparoscopic cholecystectomy

  • Remove bandages day after surgery & then can shower
  • Report signs of infection
A
  • Gradually resume activities
  • Return to work in 1 week
  • May need low-fat diet for several wks
46
Q

Ambulatory Care - Open-incision cholecystectomy

  • No heavy lifting for 4-6 wks
  • Usual activities when feeling ready
A
  • May need low-fat diet for 4-6 wks
46
Q

Ambulatory Care - Open-incision cholecystectomy

  • No heavy lifting for 4-6 wks
  • Usual activities when feeling ready
A
  • May need low-fat diet for 4-6 wks
47
Q

Expected Outcomes (for the pt w/GB dz)

  • Appear comfortable & verbalize pain relief
A
  • Verbalize knowledge of activity lvl & dietary restrictions

NUR 201 Week 10 (4 decks)

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