Chapter 44 Assessment & Management of Patients w/ Biliary Disorders Flashcards
Organs Involved in the Biliary System
Gallbladder: Bile
Pancreas
Exocrine: amylase, trypsin, lipase,
secretin
Endocrine: insulin, glucagon,
somatostatin
Gallbladder Functions
Store & excrete bile
Cholecystokinin (CKK)
Major hormone that stimulates the gallbladder contract & release digestive enzymes
Bile
Composed of H2O & electrolytes along w/ lecithin, fatty acids, cholesterol, bilirubin, & bile salts
Assist in emulsification of fats in the distal ileum
Enterohepatic Circulation
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
If the flow of bile is impeded…
…bilirubin does NOT enter the intestine & blood levels of bilirubin increase
What occurs as a result of bilirubin blood level increase?
It causes increased renal excretion of urobilinogen & decreased excretion of stool
- Urobilinogen occurs from the conversion of bilirubin in the small intestine
Cholodocholithiasis
Stones in the common bile duct
Cholecystitis
Inflammation of the gallbladder
- Can either be acute or chronic
Clinical Manifestations of Cholecystitis
Pain
Tenderness
Rigidity of the right upper abdomen, can radiate to midsternal area or right shoulder
Nausea
Vomiting
Empyema (pus) can develop
Cholelithiasis
Presence of stones in the gallbladder
- Pigment stones
- Cholesterol stones
Risk Factors for Cholelithiasis
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
Pigment Stones
Unconjugated pigments in bile form stones
Account for 10-15% of cases in the United States
Cannot be dissolved and must be removed surgically
Cholesterol Stones
Account for 75% of gallbladder disease
Decrease bile acid synthesis and increased cholesterol synthesis
Bile becomes supersaturated w/ cholesterol and form stones
Clinical Manifestations of Cholelithiasis
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
Pathological Process of Calculous Cholecystitis
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
Acalculous Cholecystitis
Describes acute gallbladder in the absence of gallstone obstruction
Occurs after:
- Major surgical procedures
- Orthopedic procedures
- Severe trauma or burns
Other Factors Associated w/ Acalculous Cholecystitis
Torsion
Cystic duct obstruction
Primarily bacterial infections of the gallbladder
Multiple blood transfusions
It is speculated that acalculous cholecystitis is caused by…
…alterations in fluids & electrolytes & alterations in regional blood flow in the visceral circulation
Bile Stasis
Caused by lack of gallbladder contraction
Risk Factors for Developing Pigment Stones
Patients w/:
- Cirrhosis
- Hemolysis
- Infections of the biliary tract
(True or False) Pigment stones do not usually require surgery, they can can dissolve on their own.
False
Pigment stones CANNOT be dissolved, they need to be removed surgically
Modifiable Risk Factors for Biliary Stone Formation
Weight
Consumption of:
- Sugar & sweet foods
- Low-fiber foods
- Fast foods
Cholelithiasis Med Management: ERCP (Endoscopic Retrograde Cholangiopancreatography)
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
Dietary Management of Cholelithiasis
Low-fat liquid diet
Advanced diet as tolerated
Avoid eating fast food, sweet & sugary foods, & low-fiber foods
Med Management of Cholelithiasis: ursodeoxycholic acid and chenodeoxycholic acid
Dissolve stones made of cholesterol
Indicated for patients refusing to go to surgery.
Med Management of Cholelithiasis: Laparoscopic cholecystectomy
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
Assessment of the Patient Undergoing Surgery for Gallbladder Disease
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)
Potential Complications for Patients Undergoing Surgery for Gallbladder Disease
Bleeding
GI symptoms related to biliary leak or injury to the bowel
Complications related to surgery in general: atelectasis, thrombophlebitis
Nursing Diagnoses for Patients Undergoing Surgery for Gallbladder Disease
Acute pain and discomfort
Impaired Gas Exchange
Impaired Skin Integrity
Impaired nutritional status
Knowledge defecit
Nursing Interventions for Patients Undergoing Surgery for Gallbladder Disease
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
Med Management of Cholelithiasis: Nonsurgical removal
Via instrumentation
Intracorporeal/extracorporeal lithotripsy: Stones are fragmented by means of laser pulse therapy
Pharmacological Management of Gallstones
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
Indications for Laparoscopic/ Open Cholecystectomy
Patients w/:
- Frequent symptoms
- Cystic duct occlusion
- Pigment stones
Gerontological Considerations for Gallstones
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
Pancreas Location
Upper abdomen
Pancreas Exocrine Secretions
Amylase, trypsin, lipase, secretin
Function of Amylase
Aids in the digestion of carbs
Function of Trypsin
Aids in digestion of proteins
Function of Lipase
Aids in digestion of fats
Pancreas Endocrine Secretions
Insulin, glucagon, somatostatin
Function of Insulin
Lowers blood glucose & promotes storage of fat in adipose tissue
- Also synthesis of protein in various tissues
Function of Glucagon
Main function is to raise blood glucose by converting glycogen into glucose in liver
Function of Somatostatin
Exerts a hypoglycemic effect by interfering w/ release of growth hormone from the pituitary & glucagon by the pancreas
Gerontological Considerations for Pancreatic Function
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
Pancreatitis
Inflammation of the pancreas
Can be acute or chronic
Which form of pancreatitis can be more life-threatening: acute or chronic?
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
Common Causes of Pancreatitis
Chronic alcohol use
Cholelithiasis
Main Differences Between Acute & Chronic Pancreatitis
Acute: Can be LIFE-THREATENING! Usually reversible
Chronic: Long-term inflammation puts them at risk of malignancy. Progressive destruction of the pancreas
Acute Pancreatitis Pathophysiology
Pancreatic duct becomes obstructed, and enzymes back up, causing autodigestion and inflammation of the pancreas
Clinical Manifestations of Acute Pancreatitis
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)
Cullen’s Sign
Superficial bruising in the subcutaneous fat around the umbilicus
Grey Turner’s Sign
An uncommon subcutaneous manifestation of intra-abdominal pathology that manifests as ecchymosis or discoloration of the flanks
Which form of acute pancreatitis is more common in patients: interstitial edematous pancreatitis or necrotizing pancreatitis?
Interstitial Edematous Pancreatitis
Mild Acute Pancreatitis
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
Severe Acute Pancreatitis
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
Gerontological Considerations for Pancreatitis
Mortality rate increases with age
Increased risk of multi-organ dysfunction
Aggressive treatment necessary to reduce mortality
Acute Pancreatitis Complications
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)
Acute Pancreatitis Diagnostic Findings
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
Acute Pancreatitis Med Management
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
Acute Pancreatitis Nursing Management: Relieving pain and discomfort
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
Acute Pancreatitis Nursing Management: Improving Breathing Pattern
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
Acute Pancreatitis Nursing Management: Improving Nutritional Status
Make the pt NPO
Admin enteral feedings & parenteral nutrition to decrease secretion of secretin
Monitor serum glucose levels q 6hrs
Acute Pancreatitis Nursing Management: Maintaining Skin Integrity
Assess wounds & draining site for infection, inflammation, & breakdown
Turn pt every 2 hrs
Perform wound care as prescribed
Acute Pancreatitis Nursing Management: Monitor & Manage Potential Complications
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
Chronic Pancreatitis Pathophysiolgy
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
Clinical Manifestations of Chronic Pancreatitis
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
Chronic Pancreatitis Diagnostic Findings
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
Chronic Pancreatitis Goals & Nursing Management
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
Chronic Pancreatitis: Surgical Treatment
Indicated when biliary disease is present or if obstruction or pseudocyst develops
Divert bile flow
Ex: Choledochojejunostmy
Or relieve ductal obstruction
Ex: Sphincterectomy
Home/Ambulatory Care for Chronic Pancreatitis
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
The client is being prepped for discharge after laparoscopic cholecystectomy. Which intervention should the nurse implement?
Include the pt’s significant other w/discharge teaching
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
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 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
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
