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Chapter 59: Care of Patients with Problems of Biliary System and Pancreas

Terms in this set (73)

Obstruction
-These organs are very close together
-Thus, problems in one may lead to problems in another
-May result from gallstones, edema, strictures and/or tumors
Obstruction (blockade) causes
inflammation
Cholecystitis
-Inflammation of gallbladder
-Occurs most commonly in affluent countries
-May be acute or chronic
-Most patients have acute type
2 types of cholecystitis
calculous and acalculous
calculous
-chemical irritation/inflammation
-Caused by gallstones that obstruct the cystic duct (most common)
OR gallbladder neck/common bile duct
Gall bladder is inflamed=trapped bile is reabsorbed=bile acts as chemical irritant=
gallbladder swells, has impaired circulation and distends=ischemia and infection
Tissue inside gallbladder necroses and dies
gangrene
Gallbladder may rupture
perforate
What may form or occur?
-Abscess may form
-Peritonitis may occur
gallstones
-Exact etiology unknown
-Believed to be link between cholesterol metabolism and bile salts
-Impaired gallbladder motility=stone formation
-Stones are composed of substances found in bile
-Bilirubin, cholesterol, bile salts, calcium
Acalculous cholesystitis
-Inflammation occurring w/o gallstones
-Associated w/biliary stasis
-Caused by any condition that affects the regular filling/emptying of the gallbladder
Acalculous cholesystitis example
sepsis/trauma/long term use of TPN, multi-organ system failure, hypovolemia, abdominal surgery
Chronic cholecystitis
-Repeated episodes of cystic duct obstruction
-Gallbladder becomes fibrotic/contracted
-Causes decreased motility and deficient absorption
-Leads to jaundice (yellowing of skin)
-Icterus (yellowing of sclera)
Chronic cholecystitis complications
pancreatitis and cholangitis (bile duct inflammation)
Chronic cholecystitis s/s
extreme pruritus/burning sensation of skin
Gallstones within the gallbladder and obstructing
the common bile and cystic ducts.
Risk factors
-chart pg 1215
-familial tendency
Physical assessment gallstones
-HISTORY
-Ht/weight/VS
-DIET: food preferences, high fat/high cholesterol?
-S/S w/diet: flatulence, dyspepsia, belching, anorexia, N/V, abdominal pain when eating high fat/high cholesterol diet?
Physical assessment: Pain
-PAIN: ask client to describe, intensity, duration, what causes pain, what makes it better, what makes it worse
-Typical description: varying indigestion
-Steady ache; usually RUQ
-Pain may radiate to R shoulder/scapula
-Pain is usually episodic
Key features
1215
Labs
-WBCs: may be elevated=infection
-AST/ALT: may be elevated=abnormal liver function
-Serum bilirubin level may be elevated
Diagnostics
-X-ray: gallstones usually easily seen
-US: RUQ: best initial dx for cholecystitis
-safe, accurate, painless
-HIDA scan: visualizes gallbladder
-Can determine patency of biliary system
-Nuclear medicine test
-MRI: reserved for complicated presentations
X-ray
gallstones usually easily seen
***US
RUQ: best initial dx for cholecystitis
-safe, accurate, painless, cheaper
HIDA scan
visualizes gallbladder
-Can determine patency of biliary system
-Nuclear medicine test
MRI
reserved for complicated presentations
Interventions: nonsurgical
PAIN control: most patients need pain meds
-opiods
-NSAIDS (Toradol) ketorolac-used for mild/moderate pain
-remember NSAIDS can cause GI bleeding
-N/V: antiemetic meds (Zofran)
-Ivs: hydration
Cholecystectomy
-Laparoscopic vs. traditional
-Laparoscopy (lap chole) is the gold standard
-Performed often
Cholecystectomy advantages
-Complications not common
-Death rate very low
-Bile duct injuries rare
-Patient recovery usually uncomplicated
-Postop pain usually mild/manageable
Traditional Cholecystectomy
-Standard preoperative care
-Operative procedure
-Postoperative care
Traditional Cholecystectomy postoperative care
-Opioids via PCA pump
-JP drain-surgical drain; prevents fluid accumulation
-Antibiotics
-Antiemetics
-Wound care
-NPO
-Nutrition therapy
Cancer of the Gallbladder
-Anorexia, weight loss, nausea, vomiting, general malaise, jaundice, hepatosplenomegaly
-Chronic, progressively severe epigastric or right upper quadrant pain
-Poor prognosis
-Surgery, radiation, chemotherapy
Acute pancreatitis
-Life-threatening inflammation of pancreas
-Severity depends on extent of inflammation and tissue damage
-Ranges from mild to diffusely bleeding pancreatic tissue (necrotizing hemorrhagic pancreatitis-NHP)
Acute pancreatitis caused by
premature activation of excessive pancreatic enzymes
Enzymes destroy ductal tissue/pancreatic cells=
autodigestion/pancreatic fibrosis
Clients with acute pancreatitis are
critically ill
Extensive pancreatic destruction leads to
shock
Shock is often
irreversible
Sock results in
client death
Complications
-Pancreatic infection=septic shock
-Hemorrhage
-Acute kidney failure
-Hypovolemic shock
-ARDS (acute respiratory distress syndrome)
-DIC (disseminated intravascular coagulation)
-Box pg 1219**
Pancreatic infection =
septic shock
ARDS*
acute respiratory distress syndrome
DIC
disseminated intravascular coagulation
-bleeding too much and clotting
Etiology
-Biliary tract disease: most common factor
-Surgical trauma
-Abdominal trauma (MVC, gunshot)
-Pancreatic obstruction (tumor)
-Other risk factors: pg 1220
Patient history:
1. Severe and constant abdominal pain-give pain meds BEFORE attempting to conduct interview
2. Alcohol use
3. Diet: does pain occur w/high fat meal?
4. Personal/family hx: alcoholism, pancreatitis, biliary tract disease
5. Have they had abdominal surgery recently?
6. Chronic illness: PUD, renal failure, vascular disorders, thyroid/parathyroid disease
7. Any recent viral illness?
Drug history
prescriptions, OTC, herbs, alternative meds, street drugs
Physical assessment: pain
-Dx made based on clinical presentations, lab tests and imaging assessments.
-PAIN: ask about location/quality
-Typical: pain onset is sudden, radiates to back/L shoulder or flank
-Pain is described as "awful"; intense, boring, continuous
-Worse by lying flat
-Better when curled into ball
Typical
pain onset is sudden, radiates to back/L shoulder or flank
Physical assessment
1. Are they jaundiced?
2. Look for grey/blue discoloration of abdomen (especially around umbilicus)
3. Look for grey/blue discoloration on flanks
4. Palpate abdomen lightly-usually tender/client may exhibit guarding
5. Monitor VS frequently
Labs
-Chart; pt 1221
-Read the lab assessment in book
-Imaging assessment pg 1221
Complications of Acute Pancreatitis
-Hypovolemia
-Hemorrhage
-Acute kidney failure
-Paralytic ileus
-Hypovolemic or septic shock
-Pleural effusion, respiratory distress syndrome, pneumonia
-Multisystem organ failure
-Disseminated intravascular coagulation
-Diabetes mellitus
Chronic Pancreatitis
Progressive destructive disease of pancreas characterized by remissions and exacerbations
Chronic Pancreatitis nonsurgical management
-Drug therapy
-Analgesic administration
-Enzyme replacement
-Insulin therapy
-Nutrition therapy
Pancreatic Abscess****
-Most serious complication of pancreatitis*
-Always fatal if untreated*
-High fever
-Blood cultures
-Drainage via percutaneous method or laparoscopy
-Antibiotic treatment alone does not resolve abscess
Pancreatic Pseudocyst complications
-Hemorrhage
-Infection
-Bowel obstruction
-Abscess
-Fistula formation
-Pancreatic ascites
Fistula
-connection of the pseudocyst and the
-connection of two things that are not normally connected
Pancreatic Pseudocyst
-May spontaneously resolve
-Surgical intervention after 6 weeks
Pancreatic Carcinoma: nonsurgical management
-Drug therapy
-Radiation therapy
-Biliary stent insertion
Pancreatic Cancer: picture
Carcinoma of the pancreas. A cross-section through the head of the pancreas and adjacent common bile duct showing both an ill-defined mass in the pancreatic substance (arrowheads) and the green discoloration of the duct resulting from total obstruction of bile flow.
Surgical Management
-Preoperative care
NG tube may be inserted
TPN typically begun
-Operative procedure may include Whipple procedure
NG
Nasogastric
TPN
total parenteral nutrition
Surgical Management postoperative care
-Observe for complications
-GI drainage monitoring
-Positioning
-Fluid and electrolyte assessment
-Glucose monitoring
...
Whipple procedure, or radical pancreaticoduodenectomy. This surgical procedure involves resection of the proximal pancreas, adjoining duodenum, distal portion of the stomach, and distal portion of the common bile duct. The pancreatic duct, common bile ducts, and stomach are anastomosed to the jejunum.
Whipple procedure
-or radical pancreaticoduodenectomy.
-This surgical procedure involves resection of the proximal pancreas, adjoining duodenum, distal portion of the stomach, and distal portion of the common bile duct. The pancreatic duct, common bile ducts, and stomach are anastomosed to the jejunum.
The three anastomoses that constitute the Whipple procedure
choledochojejunostomy, pancreaticojejunostomy, and gastrojejunostomy
Which laboratory finding corroborates the diagnosis of acute pancreatitis?

A) Serum lipase, 150 U/L
B) Serum amylase, 200 U/L
C) Serum glucose, 80 mg/dL
D)White blood cells (WBCs), 6000 mcL
Answer B:*** know these ranges:
A serum amylase of 200 U/L is elevated (normal range is approximately 23 to 85 U/L). Lipase normal range is 0-160 U/L; WBC normal range is 4800-10,800 ccm; and glucose normal range is 82-110 mg/dL. Amylase, lipase, WBC, and glucose are often higher than normal in patients with acute pancreatitis.
In preparing to care for the patient, which conditions does the nurse recognize as potential complications of acute pancreatitis? (Select all that apply.)
A) Strep throat
B) Pleural effusion
C) Diabetes mellitus
D) Pancreatic infection
E) Acute kidney failure
Answer: B, C, D, E
All, with the exception of strep throat, are potential complications of acute pancreatitis.
-When the patient is asked about pain, he says that it is intense and continuous. He states that sometimes when he curls up in a fetal position the pain eases.
-Which medication does the nurse recognize that will provide the most comprehensive pain relief at this time?
A) PCA morphine sulfate
B) IM fentanyl (Sublimaze)
C) PCA meperidine (Demerol)
D) Oral hydromorphone (Dilaudid)
Answer: A
Meperidine is not a good choice because it can cause seizures, especially in older adults. While hydromorphone is a good choice with acute pancreatitis pain, IV is the best route. Fentanyl is a good alternative, but the route chosen should be IV or transdermal. Another option is epidural analgesia.
The patient has been NPO but is now tolerating food.
-What education will the nurse provide regarding nutrition?
A) Small and frequent meals are best.
B) Use of alcohol and caffeine should be consumed in moderation.
C) Expect to experience nausea and vomiting as you begin to consume foods.
D) Low-carbohydrate, high-protein, and high-fat foods should be consumed.
Answer: A
-Patients may experience nausea and vomiting but should not expect this to happen.
-High-carbohydrate, high-protein, and low-fat foods should be included in the diet.
-Alcohol and caffeine should be avoided.
A patient with chronic cholecystitis reports pruritus, clay-colored stools, and voiding dark, frothy urine. Which laboratory analysis is a priority in the nurse's assessment of this patient?
A) Lipase level
B) Total bilirubin
C) Liver function tests
D) White blood cell count
Answer: B
-Rationale: Excess circulating bilirubin present with chronic cholecystitis is responsible for pruritus and changes in stool and urine color. -Cholecystitis is associated with several risks including hepatic disease, pancreatitis, and peritonitis.
-Monitoring liver function, pancreatic laboratory values, and white blood cell counts is also very important.
Which patient is more likely to develop gallstones?
A) 45-year-old Caucasian female with a family history of gallstones
B) 55-year-old African-American male with a history of diabetes mellitus
C) 62-year-old Hispanic/Latino female with a history of irritable bowel syndrome
D) 60-year-old obese, American-Indian female with a history of diabetes mellitus
Answer: D
-Rationale: Risk factors for developing gallstones include female gender, obesity, family history of gallstones, diabetes mellitus, American-Indian and Caucasian descent, rapid change in weight, and advanced age.
- More risk factors increase the likelihood of developing gallstones.
In the care of a patient with acute pancreatitis, which assessment parameter requires immediate nursing intervention?
A) Heart rate of 105 beats/min
B) Serum glucose of 136 mg/dL
C) Blood pressure of 102/76 mm Hg
D) Respiratory rate of 28 breaths/min
Answer: D
-Rationale: The patient with pancreatitis may develop pulmonary complications, pleural effusions, pulmonary infiltrates, and acute respiratory failure or ARDS.
-Increases in respiratory effort is an important assessment variable in the care of a patient with pancreatitis. -Patients may also be hyperglycemic and hypovolemic.
-Assessing and treating endocrine function of the pancreas and perfusion variables are also important.
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