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NURS3313 Adult Health > Chapter 44 Assessment & Management of Patients w/ Biliary Disorders > Flashcards

Chapter 44 Assessment & Management of Patients w/ Biliary Disorders Flashcards

1
Q

Organs Involved in the Biliary System

A

Gallbladder: Bile

Pancreas
Exocrine: amylase, trypsin, lipase,
secretin
Endocrine: insulin, glucagon,
somatostatin

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2
Q

Gallbladder Functions

A

Store & excrete bile

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3
Q

Cholecystokinin (CKK)

A

Major hormone that stimulates the gallbladder contract & release digestive enzymes

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4
Q

Bile

A

Composed of H2O & electrolytes along w/ lecithin, fatty acids, cholesterol, bilirubin, & bile salts

Assist in emulsification of fats in the distal ileum

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5
Q

Enterohepatic Circulation

A

1) Food enters the duodenum

2) Gallbladder contracts & sphincter of Oddi relaxes

3) Sphincter relaxation allows bile to enter the intestines

4) Bile salts work w/ cholesterol to aid in emulsification of fats in distal ileum

5) Reabsorption back into portal blood for hepatic return
- Once again excreted in bile

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6
Q

If the flow of bile is impeded…

A

…bilirubin does NOT enter the intestine & blood levels of bilirubin increase

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7
Q

What occurs as a result of bilirubin blood level increase?

A

It causes increased renal excretion of urobilinogen & decreased excretion of stool
- Urobilinogen occurs from the conversion of bilirubin in the small intestine

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8
Q

Cholodocholithiasis

A

Stones in the common bile duct

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9
Q

Cholecystitis

A

Inflammation of the gallbladder
- Can either be acute or chronic

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10
Q

Clinical Manifestations of Cholecystitis

A

Pain

Tenderness

Rigidity of the right upper abdomen, can radiate to midsternal area or right shoulder

Nausea

Vomiting

Empyema (pus) can develop

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11
Q

Cholelithiasis

A

Presence of stones in the gallbladder
- Pigment stones
- Cholesterol stones

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12
Q

Risk Factors for Cholelithiasis

A

Cystic fibrosis

Diabetes

Frequent changes in weight

Ileal resection or disease

Low-dose estrogen therapy:carries a small increase in the risk of gallstones

Obesity

Rapid weight loss (leads to rapid development of gallstones and high risk of symptomatic disease)

Treatment w/ high-dose estrogen (e.g., in prostate cancer)

Women, especially those who have had multiple pregnancies or who are of Native American or U.S. southwestern Hispanic ethnicity

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13
Q

Pigment Stones

A

Unconjugated pigments in bile form stones

Account for 10-15% of cases in the United States

Cannot be dissolved and must be removed surgically

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14
Q

Cholesterol Stones

A

Account for 75% of gallbladder disease

Decrease bile acid synthesis and increased cholesterol synthesis

Bile becomes supersaturated w/ cholesterol and form stones

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15
Q

Clinical Manifestations of Cholelithiasis

A

None or minimal symptoms, acute or chronic

Pain-excruciating upper right abdominal pain that radiates to back or shoulder

Biliary colic-caused by contraction of the gallbladder Jaundice-obstruction of the bile duct

Changes in urine or stool color-dark urine and clay-colored stools

Vitamin deficiency, fat soluble (vitamins A, D, E, and K)-obstruction interferes w/ absorption of the fat-soluble vitamins

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16
Q

Pathological Process of Calculous Cholecystitis

A

Cause of more than 90% of cases of acute cholecystitis

1) Gallbladder stone obstructs bile outflow

2) Bile remaining in the gallbladder initiates a chemical reaction
- Autolysis & edema occur

3) Blood vessels in the gallbladder are compressed-> Compromises its vascular supply
- Gangrene of the gallbladder w/perforation may occur

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17
Q

Acalculous Cholecystitis

A

Describes acute gallbladder in the absence of gallstone obstruction

Occurs after:
- Major surgical procedures
- Orthopedic procedures
- Severe trauma or burns

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18
Q

Other Factors Associated w/ Acalculous Cholecystitis

A

Torsion

Cystic duct obstruction

Primarily bacterial infections of the gallbladder

Multiple blood transfusions

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19
Q

It is speculated that acalculous cholecystitis is caused by…

A

…alterations in fluids & electrolytes & alterations in regional blood flow in the visceral circulation

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20
Q

Bile Stasis

A

Caused by lack of gallbladder contraction

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21
Q

Risk Factors for Developing Pigment Stones

A

Patients w/:
- Cirrhosis
- Hemolysis
- Infections of the biliary tract

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22
Q

(True or False) Pigment stones do not usually require surgery, they can can dissolve on their own.

A

False

Pigment stones CANNOT be dissolved, they need to be removed surgically

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23
Q

Modifiable Risk Factors for Biliary Stone Formation

A

Weight

Consumption of:
- Sugar & sweet foods
- Low-fiber foods
- Fast foods

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24
Q

Cholelithiasis Med Management: ERCP (Endoscopic Retrograde Cholangiopancreatography)

A

Patient MUST be NPO for procedure

IV sedation and anesthesia

Observe for signs of CNS and respiratory depression

Monitor vital signs and signs of perforation or infection

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25
Q

Dietary Management of Cholelithiasis

A

Low-fat liquid diet

Advanced diet as tolerated

Avoid eating fast food, sweet & sugary foods, & low-fiber foods

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26
Q

Med Management of Cholelithiasis: ursodeoxycholic acid and chenodeoxycholic acid

A

Dissolve stones made of cholesterol

Indicated for patients refusing to go to surgery.

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27
Q

Med Management of Cholelithiasis: Laparoscopic cholecystectomy

A

Standard of therapy

Performed through a small incision/puncture through abdominal wall

Pts do not develop paralytic ileus

Pts discharged the same day or w/in 1-2 days

Bile duct injury most common complication

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28
Q

Assessment of the Patient Undergoing Surgery for Gallbladder Disease

A

Patient history-smoking, respiratory problems Knowledge and education needs-avoid smoking, aspirin, NSAIDs (bleeding)

Respiratory status and risk factors for postoperative respiratory complications

Nutritional status-dietary history/lab values

Monitor for potential bleeding

GI symptoms: after laparoscopic surgery, assess for loss of appetite, vomiting, pain, distention, fever (potential infection or disruption of GI tract)

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29
Q

Potential Complications for Patients Undergoing Surgery for Gallbladder Disease

A

Bleeding

GI symptoms related to biliary leak or injury to the bowel

Complications related to surgery in general: atelectasis, thrombophlebitis

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30
Q

Nursing Diagnoses for Patients Undergoing Surgery for Gallbladder Disease

A

Acute pain and discomfort

Impaired Gas Exchange

Impaired Skin Integrity

Impaired nutritional status

Knowledge defecit

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31
Q

Nursing Interventions for Patients Undergoing Surgery for Gallbladder Disease

A

Place patient in low Fowler’s position

Manage NG tube or make the patient NPO until bowel sounds return; then a soft, low-fat, high-carbohydrate diet

Manage care of biliary drainage system: Note output and drainage color

Administer analgesics, pain management

Encourage patient to turn, cough, and deep breathe; splinting to reduce pain

Promote early ambulation

Check puncture site daily for infection, allow adhesive strips to fall off

32
Q

Med Management of Cholelithiasis: Nonsurgical removal

A

Via instrumentation

Intracorporeal/extracorporeal lithotripsy: Stones are fragmented by means of laser pulse therapy

33
Q

Pharmacological Management of Gallstones

A

Ursodeoxycholic acid (UDCA) & chenodial are used to dissolve small, radiolucent stones composed of cholesterol
- Desaturates bile via inhibition of cholesterol secretion & synthesis

6-12 months of therapy is required in many patients to dissolve stones

Potential Side Effects:
- GI symptoms
- Pruritis
- Headache

34
Q

Indications for Laparoscopic/ Open Cholecystectomy

A

Patients w/:
- Frequent symptoms
- Cystic duct occlusion
- Pigment stones

35
Q

Gerontological Considerations for Gallstones

A

Surgical intervention for diseases of the bile duct tract is more common in older adults

Cholesterol saturation of bile increases w/ age
- Increased hepatic secretion of bile
- Decreased bile acid synthesis

May not exhibit typical symptoms (fever, pain, chills, jaundice)
- Symptoms may be preceded or accompanied by symptoms of septic shock
- Oliguria
- Hypotension
- Changes in LOC
- Tachycardia & tachypnea

36
Q

Pancreas Location

A

Upper abdomen

37
Q

Pancreas Exocrine Secretions

A

Amylase, trypsin, lipase, secretin

38
Q

Function of Amylase

A

Aids in the digestion of carbs

39
Q

Function of Trypsin

A

Aids in digestion of proteins

40
Q

Function of Lipase

A

Aids in digestion of fats

41
Q

Pancreas Endocrine Secretions

A

Insulin, glucagon, somatostatin

42
Q

Function of Insulin

A

Lowers blood glucose & promotes storage of fat in adipose tissue
- Also synthesis of protein in various tissues

43
Q

Function of Glucagon

A

Main function is to raise blood glucose by converting glycogen into glucose in liver

44
Q

Function of Somatostatin

A

Exerts a hypoglycemic effect by interfering w/ release of growth hormone from the pituitary & glucagon by the pancreas

45
Q

Gerontological Considerations for Pancreatic Function

A

People older than 70 y.o.: Increase in fibrous material & fatty deposits w/in the pancreas

Decreased rate of pancreatic enzyme secretion & decreased bicarbonate output

Impairment of “normal” fat absorption w/ increasing age due to delayed gastric emptying & pancreatic insufficiency

Decreased Ca+2 absorption may also occur

  • These changes require care in interpreting diagnostic results & in providing dietary counseling
46
Q

Pancreatitis

A

Inflammation of the pancreas

Can be acute or chronic

47
Q

Which form of pancreatitis can be more life-threatening: acute or chronic?

A

Acute can be a medical emergency associated w/ high risk of life-threatening complications & mortality

Chronic often goes undetected since classic clinical & diagnostic findings are not always present in the early stages

48
Q

Common Causes of Pancreatitis

A

Chronic alcohol use

Cholelithiasis

49
Q

Main Differences Between Acute & Chronic Pancreatitis

A

Acute: Can be LIFE-THREATENING! Usually reversible

Chronic: Long-term inflammation puts them at risk of malignancy. Progressive destruction of the pancreas

50
Q

Acute Pancreatitis Pathophysiology

A

Pancreatic duct becomes obstructed, and enzymes back up, causing autodigestion and inflammation of the pancreas

51
Q

Clinical Manifestations of Acute Pancreatitis

A

Severe abdominal pain is the major symptom that causes the patient to seek medical care
- Abdominal pain & tenderness & back pain are due to irritation & edema of the pancreas
- Pain occurs in the midepigastrum
- Frequently acute in onset: Occurs 24-48 hrs after heavy meal or alcohol ingestion
- May be diffuse & difficult to localize

Abdominal distension
- Poorly defined palpable abdominal mass
- Rigid or board-like abdomen may develop (peritonitis)

Ecchymosis (bruising) of the flank or around umbilicus-> severe pancreatitis

Bowel sounds decreased or absent

Low-grade fever, leukocytosis

Hypotension, tachycardia

Cyanosis, dyspnea

Jaundice

Abnormal lung sounds - crackles, diminished sounds
Discoloration of the abdominal wall - Turner’s or Cullen’s sign

SIGNS OF SHOCK- Vital signs (increased respirations, tachycardia, hypotension)

52
Q

Cullen’s Sign

A

Superficial bruising in the subcutaneous fat around the umbilicus

53
Q

Grey Turner’s Sign

A

An uncommon subcutaneous manifestation of intra-abdominal pathology that manifests as ecchymosis or discoloration of the flanks

54
Q

Which form of acute pancreatitis is more common in patients: interstitial edematous pancreatitis or necrotizing pancreatitis?

A

Interstitial Edematous Pancreatitis

55
Q

Mild Acute Pancreatitis

A

AKA Interstitial Edematous Pancreatitis

Characterized by lack of pancreatic or peripancreatic parenchymal necrosis w/ diffuse enlargement of the gland due to inflammatory edema

Edema & inflammation are self-limited to the pancreas

Minor organ dysfunction: Should return to normal function w/in 6 months

Acutely ill: Risk for hypovolemic and Septic shock

56
Q

Severe Acute Pancreatitis

A

AKA Necrotizing Pancreatitis

Characterized by tissue necrosis in either the pancreatic parenchyma or in the tissue surrounding the gland

Can either be sterile or infected

If parenchyma is involved-> marker for more serious disease
- Rapidly fatal
- More complete enzyme digestion
- Local blood vessels damage

Local Implications Include:
- Pancreatic cysts
- Abscesses
- Acute fluid collections in or near the pancreas

Bleeding & Thrombus Systemic Complications:
- Organ Failure (pulmonary insufficiency, hypoxemia)
- Kidney disease
- GI bleed
- Shock

57
Q

Gerontological Considerations for Pancreatitis

A

Mortality rate increases with age

Increased risk of multi-organ dysfunction

Aggressive treatment necessary to reduce mortality

58
Q

Acute Pancreatitis Complications

A

Fluid and electrolyte disturbances: hypocalcemia, hypotension, low UO

Necrosis of the pancreas: due to hemorrhage and septic shock

Shock: hypovolemia, bacterial infection, and fluid in the peritoneal cavity

Multiple organ dysfunction syndromes (MODS) Disseminated intravascular coagulation (DIC)

59
Q

Acute Pancreatitis Diagnostic Findings

A

Serum amylase (25-125 U/L)

  • > 200 U/L for 24-72 hours
  • Starts to rise 2-6 hours after onset of pain

-Peaks @ 24 hours

-Return to normal @ 72 hours

Serum lipase (3-19 U/dL): used with amylase; rises later than amylase (48 hours)

-Return to normal 8-14 days

Increased WBC’s > 16, 000 mm3

Increased glucose > 200 mg/dL

Increased lipids LDH > 350 IU/L

Decreased calcium < 8mg/dL

60
Q

Acute Pancreatitis Med Management

A

Antibiotics for infection

Correction of blood, fluid loss, and low albumin levels. Insulin therapy for critically ill patients

Respiratory care because of the hypoxemia

Biliary Drainage-reestablish drainage of the pancreas Diagnostic laparotomy -surgery to establish pancreatic drainage

D/C thiazide diuretics, corticosteroids, oral contraceptives

Low fat and protein diet

No alcohol or caffeine

61
Q

Acute Pancreatitis Nursing Management: Relieving pain and discomfort

A

Assess pain level

Administer IV opioid analgesics via PCA pump

Place pt in side-lying position

Maintain bed rest in acutely ill-decrease metabolic rate

Manage NG tube to relieve N/V and oral hygiene to decrease discomfort from NG tube

62
Q

Acute Pancreatitis Nursing Management: Improving Breathing Pattern

A

Administer Oxygen

Elevate HOB, Place in Semi-Fowler’s position
- Decreases pressure on diaphragm due to distention

Position changes to prevent atelectasis and pooling of secretions and pneumonia

Monitor for atelectasis, pleural effusions

Encourage TCDB, incentive spirometer

63
Q

Acute Pancreatitis Nursing Management: Improving Nutritional Status

A

Make the pt NPO

Admin enteral feedings & parenteral nutrition to decrease secretion of secretin

Monitor serum glucose levels q 6hrs

64
Q

Acute Pancreatitis Nursing Management: Maintaining Skin Integrity

A

Assess wounds & draining site for infection, inflammation, & breakdown

Turn pt every 2 hrs

Perform wound care as prescribed

65
Q

Acute Pancreatitis Nursing Management: Monitor & Manage Potential Complications

A

Administer IV fluids and blood products for hypovolemic shock

Administer IV calcium gluconate and magnesium sulfate for low magnesium and calcium levels

Monitor hemodynamics in ICU for patients with pancreatic necrosis

Nursing management in ICU for Shock, DIC, and MODS:

-Assist with ventilator management

-Monitoring hemodynamics

-Prevent additional complications

66
Q

Chronic Pancreatitis Pathophysiolgy

A

A progressive inflammatory disorder w/the destruction of the pancreas; cells are replaced by fibrous tissue; pressure within the pancreas increases, obstructing the pancreatic and common bile ducts

67
Q

Clinical Manifestations of Chronic Pancreatitis

A

Abdominal pain: Located in the same areas as in acute pancreatitis

-Heavy, gnawing feeling; burning and cramp-like Malabsorption with weight loss

Constipation

Mild jaundice with dark urine ( “tea-colored”)

Steatorrhea: fatty, foul-smelling stool

Frothy urine/stool

Diabetes

68
Q

Chronic Pancreatitis Diagnostic Findings

A

Lab Tests:

Serum amylase/lipase: May be ↑ slightly or not at all

↑ Serum bilirubin

↑ Alkaline phosphatase

Mild leukocytosis

Elevated sedimentation rate

Diagnostics:

-ERCP

-CT

-MRI

-Ultrasound

69
Q

Chronic Pancreatitis Goals & Nursing Management

A

Prevent acute exacerbations

Pain relief

Control of pancreatic exocrine and endocrine insufficiency

-Pancreatic enzyme replacement; bile salts

-Acid-neutralizing and acid-inhibiting drugs

Low fat, high-carbohydrate diet

-Recognize and address effects of malabsorption

Avoid crash diets and binging

70
Q

Chronic Pancreatitis: Surgical Treatment

A

Indicated when biliary disease is present or if obstruction or pseudocyst develops

Divert bile flow
Ex: Choledochojejunostmy

Or relieve ductal obstruction
Ex: Sphincterectomy

71
Q

Home/Ambulatory Care for Chronic Pancreatitis

A

Focus is on chronic care and health promotion

Dietary control:

-No alcohol

-Avoid caffeine

-Low fat, high carbohydrate diet

-Avoid crash diets and binging

Smoking cessation

Control of diabetes

Taking pancreatic enzymes CORRECTLY

Patient and family teaching r/t disease progression

72
Q

The client is being prepped for discharge after laparoscopic cholecystectomy. Which intervention should the nurse implement?

A

Include the pt’s significant other w/discharge teaching

73
Q

A nurse is providing discharge teaching for laparscopic cholecystectomy. Which post-op instructions should be included?

A) Take baths rather than showers
B) Take off adhesive after 24 hrs
C) Continue diet of choice

A
74
Q

The nurse is caring for a newly admitted client with acute pancreatitis. Which interventions should the nurse implement?

A) NS 1000mL IV over 1 hr, then IV fluids at 250 ml/hr

B) Initiate NG tube feedings w/ low-fat formula

C) Vital signs every shift

D) Up to chair for meals & ambulate 4X daily

A
75
Q

A nurse receives report on 4 assigned clients. Prioritize the order that the nurse should assess the clients.

47 year old client 2 days post-cholecystectomy who has pain rated 2/10

57-year-old w/ possible acute pancreatitis, severe abd pain, low O2 & BP

64-year-old w/ cirrhosis, jaundice, itching, & elevated ammonia level

82 yr old who is unable to void w/ bladder scan showing 300 mL of urine

A

57-year-old w/ possible acute pancreatitis, severe abd pain, low O2 & BP

64-year-old w/ cirrhosis, jaundice, itching, & elevated ammonia level

82 yr old who is unable to void w/ bladder scan showing 300 mL of urine

47 year old client 2 days post-cholecystectomy who has pain rated 2/10

NURS3313 Adult Health (27 decks)

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