Biliary, Exocrine & Hepatic Disorders (Day 2) Flashcards

Question

Cholecystectomy

Answer 1

Excision of gall bladder from posterior liver wall Ligation of cystic duct, vein & artery T-tube ensures adequate bile drainage during duct healing (with Open procedure) Laparoscopic Contra-indicated with stones in common bile duct

Answer 2

Monitor for complications & provide analgesia Referred pain to shoulder pain from CO2 Sims’ position Deep breathing, ambulation Clear liquids 1st day; Light meals for a few days Discharged same day Remove bandages POD#1 and can shower Report signs of infection Gradually resume activities; Return to work in 1 week Patient teaching Teach what to report & Follow-up care May need low-fat diet for several weeks Weight reduction if needed Fat-soluble vitamin supplements

Answer 3

Maintain adequate ventilation, prevent pulmonary complications General postoperative nursing care Maintain drainage tubes (T-tube, Penrose, or J-P) Replace lost fluids and electrolytes CL, the ADAT once bowel sounds have returned Patient Teaching: No heavy lifting for 4 - 6 weeks Usual activities when feeling ready May need low-fat diet for 4 - 6 weeks Weight reduction if needed Fat-soluble vitamin supplements What to report & Follow-up care

Answer 4

Inserted into Common Bile Duct during Open Cholecystectomy; Drains bile while duct heals & small intestine adjusts

Answer 5

Endoscope passed to duodenum then retrograde up into duct Visualization & dilation Placement of stents Open sphincter of Oddi, if needed Stones removed with basket or allowed to pass in stool Extracorporeal shock-wave lithotripsy (ESWL) If stones cannot be removed via endoscope High-energy shock waves disintegrate gallstones Takes 1 - 2 hours Used in conjunction with bile acids

Answer 6

Oral dissolution therapy Ursodeozycholic acid (Ursodiol or Actigal) 300 mg tablets; 600 mg / day; 300 mg two times/day Therapy takes average of 1-3 months; up to 12 months (https://www.rxlist.com/actigall-drug.htm#description) Bile Acid Sequestrants; Given for pruritus or loose stools Colestipol (Colestid): 2000 mg tablets PO 1 – 2 times/day Cholestyramine (Questran) 4 to 8 grams 1 – 2 times/day (Max 24-grams/day) Powder, mixed with milk or juice Monitor N/V, diarrhea or constipation, skin reactions Check drug-to-drug interactions

Answer 7

Preoperative or palliative When endoscopic drainage fails Inserted percutaneously and attached to drainage bag Replace fluids lost with electrolyte-rich drinks Skin care important

Answer 8

End-stage of liver disease; Extensive degeneration & destruction of liver cells Replacement of liver tissue by fibrous & regenerative nodules Chronic, progressive; Usually happens after decades of chronic liver disease Alcoholic (Laennec’s) Chronic HCV Post-necrotic Macro-nodular Toxin-induced Biliary and/or Cardiac Portal Vein Hypertension Bleeding varices Ascites Increased ammonia (encephalopathy) Incomplete clearing of protein waste Jaundice Skin Lesions; Increase in circulating estrogen d/t inability of liver to metabolize steroid hormones Spider angiomas (telangiectasia or spider nevi) Palmar erythema

Answer 9

Peripheral neuropathy Common in alcoholic cirrhosis Dietary deficiencies of thiamine, folic acid, & cobalamin Sensory & motor symptoms Hepato-renal syndrome Renal failure with azotemia, oliguria, and intractable ascites No structural abnormality of kidneys Portal hypertension leads to vasodilation which leads to renal vasoconstriction Treat with liver transplantation

Answer 10

Hepatic encephalopathy (Neurotoxic effects of ammonia); Liver unable to convert increased ammonia to urea, Ammonia crosses blood-brain barrier Changes in neurologic and mental responsiveness Impaired consciousness Inappropriate behavior Sleep disturbances, trouble concentrating, coma Asterixis Flapping tremors; Most common in arms & hands Impairment in writing; Difficulty in moving pen left to right Fetor hepaticus Musty, sweet odor of patient’s breath

Answer 11

Liver enzyme tests (Alkaline phosphatase, AST, ALT, GGT) Total protein, albumin levels Serum bilirubin, globulin levels Cholesterol levels Prothrombin time Ultrasound elastography (Fibroscan) Liver biopsy

Answer 12

Assess response to altered body image Supportive listening Rest Prevent complications Modify schedule Minimize or avoid: ASA Acetaminophen NSAIDs Monitor color of urine & stools Daily weights, accurate I & O Extremities measurement Abdominal girth Monitor for fluid & electrolyte imbalances Hypokalemia Water excess (hyponatremia) Observe for bleeding tendencies

Answer 13

Diet for patient without complications High Carb / Calorie (3000 cal/day) Moderate to low fat Protein restriction rarely needed Oral hygiene Between-meal snacks Offer preferred foods Explanation of dietary restrictions Seasonings to make food more palatable Administration of B-complex vitamins Avoidance of alcohol Protein supplements for protein-calorie malnutrition Low-sodium diet for patient with ascites & edema Dietitian referral / consult

Answer 14

Assess for jaundice Measures to relieve pruritus Cholestyramine or hydroxyzine Baking soda or Alpha Keri baths Lotions, soft or old linen Antihistamines Temperature control Short, clean nails; Scratch with knuckles rather than nails Control of temperature

Answer 15

Prevent bleeding/hemorrhage Avoid alcohol, aspirin, & NSAIDs Screen for with endoscopy Nonselective β-blocker If bleeding occurs, stabilize patient, manage airway, start IV therapy & blood products Drug therapy Octreotide Vasopressin Support for acute bleed FFP, PRBCs Vitamin K PPI’s Lactulose (Cephulac) & Rifaximin (Xifaxan) Antibiotics Sclerotherapy Balloon tamponade; Mechanical compression (Scissors at bedside) Sengstaken-Blakemore tube Minnesota tube Linton-Nachlas tube LT Management Nonselective Beta-blockers Repeated band ligation

Answer 16

Shunting Procedures Done more after second major bleeding episode Nonsurgical: Transjugular Intrahepatic Portosystemic shunt (TIPS) Surgical: Portacaval or Distal Splenorenal shunt

Answer 17

Relief of dyspnea Semi- or high Fowler’s position Skin care Special mattress Turning schedule, at least every 2 hours ROM exercises Coughing/deep breathing exercises Elevate lower extremities (and scrotum PRN) Sodium restriction Diuretics, fluid removal Albumin Tolvaptan (Samsca) Paracentesis Transjugular intrahepatic portosystemic shunt (TIPS) Peritoneovenous shunt Rarely used High rate of complications

Answer 18

Have patient void immediately before High Fowler’s position or sitting on side of bed Monitor for hypovolemia & electrolyte imbalances Monitor BP & heart rate Monitor dressing for bleeding/leakage

Answer 19

Treatment of precipitating cause Control factors known to precipitate encephalopathy Lower dietary protein intake Control GI bleeding & remove blood from GI tract Maintain safe environment; Assess: LOC & neuro status every 2-hours Sensory & motor abnormalities; Prevent falls & injuries Fluid & electrolyte imbalances; Acid-base imbalances Response to treatment measures Reduce ammonia formation Lactulose (Cephulac), traps ammonia in gut, expelled with stool Rifaximin (Xifaxan) antibiotic Prevent / minimize constipation Encourage fluids

Answer 20

Supportive measures: Rest, Maintain adequate nutrition; Proper diet Reduce or eliminate risk factors Abstinence from alcohol and/or treat alcoholism Bariatric surgery for morbidly obese Avoiding potentially hepatotoxic OTC drugs Community support programs Patient education re: symptoms of complications & when to seek medical attention Written instructions with adequate explanations for patient/family Referral to community or home health nurse

Answer 21

Primary (Benign or Malignant): Can originate from hepatocytes, connective tissue, blood vessels, bile ducts Benign: 90% are women taking BCP’s Metastatic: GI tract (Colon), breasts, lungs Resection only method of cure & only if confined to one lobe Poor prognosis; 6 - 12 months Most common d/t hepatic encephalopathy or blood loss from GI bleeding