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Terms in this set (53)

- Nursing Management - Nursing Interventions :

■ Assessments
• Vital signs
- Fever and tachycardia may represent inflammation due to gallstones. Elevated respiratory rate may occur because of anxiety and pain, the rate may be shallow and rapid because of pain, and blood pressure may be low as a result of dehydration/inflammatory response.

• Serum electrolytes
- These measure imbalanced electrolytes due to dehydration from nausea and vomiting and lack of oral intake and include BUN and creatinine (elevated). In the patient with nasogastric tube suctioning, the serum potassium should be monitored closely because this electrolyte is lost with nasogastric suctioning.

• Serum WBC
- Inflammation leads to an elevated WBC count.

• Liver enzymes, bilirubin
- Liver enzymes (AST, ALT, LDH, ALP) and bilirubin are elevated because of blockage of bile flow in the bile ducts.

• Skin turgor
- Decreased skin turgor indicates dehydration.

• Pain (onset, duration, exacerbating and relief factors)
- Pain can be intermittent and colicky. Pain can be severe epigastric and in the RUQ with radiation to the back, mid-shoulder/scapula, or in the chest. The onset is fast, commonly within 1 hour of eating a high-fat meal, and common at night.

• Abdominal assessment: distention, bowel sounds; Murphy's sign
- Palpation may reveal rebound tenderness, muscle guarding, or rigid abdominal muscles due to pain.

• Stool
- Steatorrhea (presence of excess fat in stool or oily stools), clay-colored stools due to blockage of bile flow

• Daily weight
- Provides information in regard to fluid gains or losses

• Intake and output
- Provide data about fluid volume status and prevent dehydration

• Nutritional intake
- Determines diet history, fat intake, foods that can contribute to symptoms

■ Actions
• Maintain NPO status.
- NPO status prevents gallbladder contraction that releases bile to break down nutrients; these contractions cause pain because of the inflamed gallbladder.

• Administer ordered antibiotics.
- A short course of antibiotics may be given to reduce inflammation and treat infection.

• Administer ordered bile acid reducers.
- Bile acid reducers help dissolve gallstones.

• Administer analgesics as ordered.
- Analgesics decrease the patient's symptoms of pain. Avoid morphine due to spasm of the sphincter of Oddi.

• Administer antiemetic as ordered.
- Antiemetics decrease symptoms of nausea and vomiting, which may occur for a prolonged time due to abdominal pain and obstruction.

• Promote bedrest in semi-Fowler's position.
- Avoid lying flat because this makes the pain worse, particularly with peritonitis, by stretching the abdominal muscles when supine. Repositioning helps alleviate abdominal pain and pressure.

• Nasogastric tube (NGT) to low suction (intermittent or continuous is ordered based on type of tube)
- An NGT is used to decompress the stomach and remove gastric secretions.

■ Teaching
• Postoperative instructions
- Discharge teaching includes signs and symptoms of infection, prevention of constipation, low-fat diet, and activity restrictions (encourage walking and normal activity within a week, such as driving, working, and light lifting of less than 10 pounds), and no driving while taking narcotics.

• T-tube management
- The patient needs to monitor the insertion site for inflammation and drainage. The T-tube bag should be emptied when one-half to two-thirds full to decrease the pull on the insertion site.

• The patient should avoid a diet high in saturated fats.
- Obtaining a diet history can help identify foods that contribute to symptoms. Bile breaks down fats; thus, a diet high in fat requires activation of bile for breakdown and increases pain. Stress small, frequent meals.

• Disease clinical manifestations, progression, diagnostic procedures, and interventions
- Patient education about the disease improves overall management and health. It is important that the patient recognize and report symptoms that may indicate relapse or complications, including pain, chills, fever, jaundice, dark urine, and light (clay-colored) stools.
- Diagnosis Tests :


- Abdominal x-ray is occasionally used to detect calcified gallstones

- Abdominal ultrasonography
--Noninvasive test that is most commonly used to determine the presence of gallstones and acute cholecystitis. A thickened gallbladder is indicative of cholecystitis

- Computed tomography (CT) visualizes the entire abdomen and can detect the presence of gallstones

- The hepatobiliary iminodiacetic acid (HIDA) scan
-- Nuclear medicine scan that uses a radioactive tracer to study the production and flow of bile, visualizing the liver, gallbladder, bile ducts, and small intestine

- Endoscopic retrograde cholangiopancreatography (ERCP)
-- Allows visualization of the common bile duct where gallstones can be removed. In patients with acalculous cholecystitis who are a high operative risk, a percutaneous drain can be placed. Patients who undergo ERCP should not eat or drink anything the night before the procedure but can take their cardiac and blood pressure medications the morning of the examination with a small amount of water. Patients are sedated for the test and need to have someone drive them home. After the ERCP, the patient goes to the postanesthesia care unit (PACU) to allow time for recovery from the sedation. It is important that the nurse observed the patient after the ERCP for a potential systemic inflammatory response syndrome (SIRS) caused by the manipulation of the bile ducts and potential bacterial translocation

- Cholangiogram and lab work
-- Commonly used in the operating room to image the biliary tree. A radiopaque dye, usually containing iodine, is injected intravenously, which outlines the bile ducts and gallstones

- Lab work :


- CBC & liver function tests:
-- Elevated WBC due to inflammation
-- Elevated liver enzymes, including AST, ALT, lactate dehydrogenase (LDH), and alkaline phosphatase (ALP), as well as bilirubin because of blockage of bile flow in the bile ducts
- Gallstone in the common bile duct
- Gallstones are most commonly found blocking the cystic duct or the common bile duct
- Surgical Options :

ERCP with sphincterotomy :
- Visualization
- Dilation
- Placement of stents
- Open sphincter of Oddi, if needed
- Endoscope passed to duodenum
- Stones removed with basket or allowed to pass in stool

Laparoscopic Cholecystectomy :
- Treatment of choice
- Removal of gallbladder through 1 to 4 puncture holes
- Minimal postoperative pain
- Resume normal activities, including work, within 1 week
- Few complications

Laparoscopic Cholecystectomy Surgery and care :
- Carbon dioxide gas is inserted to create space in the abdomen, and the surgical instruments and a laparoscope (a small thin telescope, camera, and surgical equipment) are placed through the incisions to remove the gallbladder.
- This procedure involves general anesthesia and can be done on an outpatient basis or may require the patient to stay in the hospital overnight

Post-Op :
- Immediate post-op : patient recovers from anesthesia in the postanesthesia care unit (PACU), where the nurse monitors vital signs, pain, neurological status, nausea and vomiting, and the surgical site for distention, bleeding, or bruising
- Once the patient is awake and following commands :
-- Clear liquids are given slowly in small amounts to prevent nausea and vomiting
-- After the first 12 hours of liquids and no nausea, vomiting, or abdominal cramping, patients can gradually introduce small amounts of solid foods and maintain a low-fat diet

Discharge Instructions :
- Incision care :
-- Keep Band-Aid or dressing on for first 24 hours and then remove
- Recognize signs & symptoms of infection :
-- Signs of jaundice (yellow eyes or skin)
- Pain medication instruction
- Constipation prevention
- Activity level :
-- Encourage walking and normal activity within a week, such as driving, working, and light lifting of less than 10 pounds
-- No driving while taking narcotics
-- Teach patients that it is okay to take a shower after the first 48 hours and get the incision a little wet in the shower, but patients should not let the water pressure flow directly on the incision, which can increase chances of infection at the incision site
--- No soaking in a tub, pool, or hot tub for up to 1 week
-- Pain after a laparoscopic cholecystectomy can occur at the incisions and sometimes in one or both of the shoulders because of irritation of the diaphragm from the carbon dioxide gas given during the surgery

Open Cholecystectomy :
- If patient has complications such as perforated gallbladder or peritonitis :
-- An open surgical procedure may be indicated
- Open cholecystectomy may also be indicated if the patient has a history of previous abdominal surgeries (because of scarring and adhesions) or is morbidly obese
- About 5% of laparoscopic procedures are converted to open procedures if :
-- There is an injury to a blood vessel
-- Difficulty removing or visualizing the gallbladder
-- Other reasons as determined by the surgeon during the procedure
- Removal of the gallbladder through an open incision in the abdomen and is performed under general anesthesia
-- Most common means of removal of the gallbladder prior to the development of laparoscopy
- Open Cholecystectomy Post-Op Care :
-- Monitoring :
--- Vital signs
--- Pain
--- Neurological status
--- Abdomen for signs & symptoms of :
---- Distention
---- Bleeding
---- Bruising
-- Once patient is passing flatus (fart) :
--- Clear liquids are introduced
--- Diet is advanced to regular if the patient has no nausea or vomiting
-- Pain management :
--- Patient-controlled analgesia
--- PRN
-- Pulmonary interventions to encourage lung expansion :
--- Coughing & deep breathing to prevent pneumonia and atelectasis
--- Walking is encouraged
-- Discharge teaching :
--- Signs & symptoms of infection
--- Prevention of constipation
--- Low-fat diet
--- Activity levels
--- If T-tube is present :
---- Routine care
---- Teaching of t-tube management are necessary
-- Patient is typically in the hospital for several days after open cholecystectomy

T-tube :
- If stones are present in the common bile duct, surgeons may place a T-tube, or biliary drainage tube, into the common bile duct to monitor bile drainage. This tube exits the patient's abdomen through the skin and is connected to a closed drainage system. This tube may stay in place for up to 2 weeks after surgery. Bile output should not exceed 500 mL in the first 24 hours
- T-tube Post-Op Care :
-- Assessment of the characteristics of the drainage :
--- Color
--- Consistency
--- Amount
-- Routine emptying of the contents of the drainage bag
-- Skin care
-- Routine flushing with appropriate preservative-free solution as ordered
- T-tube Patient Teaching :
-- Information about care
-- Biliary drainage
-- Clinical manifestations of obstruction
-- Color of urine and stool (if bile is being drained outside of body)
Infection

Pain Management :
- Narcotics such as meperidine (Demerol) can be used for severe pain management
- Acetaminophen or nonsteroidal medications such as
-- Ibuprofen
-- Naproxen
-- Can also be used for pain management in patients with less severe pain
- Toradol
- Gas pain, heating pad on low heat
B. Acute Pancreatitis Epidemiology :

- Patients usually present with life-threatening conditions that require hospitalization, frequently in ICU
- Acute pancreatitis is an inflammation of the pancreas that can be mild to severe and affect people of all ages...
- Acute pancreatitis : the pancreatic duct becomes obstructed and enzymes back up into the pancreatic duct, causing auto digestion and inflammation of the pancreas
- Serum amylase and lipase levels are used in making the diagnosis of acute pancreatitis, although their elevation can be attributed to many other causes
- The most prevalent causes of acute pancreatitis are :
-- Gallstones
--- Due to presence of gallstones obstructing bile duct or located near the area where the bile duct and pancreatic duct empty into the duodenum
--- Causing alteration in the flow of bile & pancreatic enzymes and leading to inflammation of the pancreas
--- More common in women, incidence increases with every decade of life
--- Cannabis has recently been identified as a possible risk factor due to toxin release in a small number of reports
-- Alcohol
--- Approx. ⅓ of all cases of pancreatitis
--- More common in men because increased frequency of heavy alcohol consumption in males
-- Mild Pancreatitis :
--- Have no end-organ dysfunction
--- Low mortality rate (<1%)
--- Self-limiting
--- 85% of patients fully recover
-- Severe Acute Pancreatitis :
--- May develop SIRS & end-organ dysfunction
--- Mortality rate of 15% to 30%
--- More frequent in males than females
--- Acute pancreatitis occurs over all age spans
--- Risk of pancreatitis :
--- 2 to 3 times higher among African Americans than Causcasians
-- Chronic Pancreatitis :
---Persistent inflammation that causes scarring and damage to the pancreas and surrounding tissue
- D. Pancreatic Cancer Epidemiology :

- Pancreatic cancer is the fourth most common cause of cancer related deaths in the United States
- In 2017, the American Cancer Society reported that over 50,000 people were diagnosed with pancreatic cancer
- Approx. :
-- 23% of patients survive to 1 year after diagnosis
-- Only 5% survive to 5 years
--- Because early surgical resection of small pancreatic tumor that has no lymph node involvement can reach 40%
--- Uncommon because patients are usually diagnosed late
- Almost 80% of patients with cancer of the pancreas have unresectable tumors because the diagnosis occurs late in the disease process
- There is no reliable screening test for the early detection of pancreatic cancer, and clinical manifestations are usually vague and similar to those of other GI disorders
- Exact cause of pancreatic cancer is not known
- High association with behaviors such as :
-- Cigarette smoking
--- Doubles risk & is associated with diagnosis at an early age
--- Important to teach smoking cessation because this is one of the leading preventable causes of pancreatic cancers
-- Diets high in fat
-- Consumption of meat
-- Fried foods
-- Refined sugars
-- Nitrates
-- All of which are modifiable risk factors
- Also higher risk in patients with :
-- Diabetes
--- Patients with diabetes mellitus that is diagnosed later in life (after age 50) are at increased risk
-- Chronic pancreatitis
-- Family history of pancreatic cancer
-- People of Ashkenazi Jewish descent
- Risk increases with :
-- Age & is commonly diagnosed in people over the age of 60 years
-- People of African American descent are at higher risk than people of European descent
-- More common in men
-- Some occupational exposure to toxins such as :
--- Gasoline derivatives
--- Other chemicals
--- May predispose patient to higher risk
- Majority of pancreatic cancers are adenocarcinomas (type of cancer that forms in the glands that secrete mucus)
-- Develop in the exocrine portion of the pancreas
- Adenocarcinoma is a malignant tumor that grows on the epithelial cells of an organ
-- Fast growing & spread to other local organs
-- Primarily :
--- Stomach
--- Duodenum
--- Gallbladder
--- Liver
--- Intestines
-- Metastasis occurs through invasion of the lymph & vascular systems and can spread to :
--- Lung
--- Peritoneum
--- Spleen
-- Most common pancreatic cancer :
--- Ductal adenocarcinoma (75%-93%)
--- Most frequently found in the head of the pancreas
-- Other types of pancreatic cancers :
--- Occur in the endocrine tissues of the pancreas
--- Produce hormones & named according to the hormones they produce
--- I.e. insulinoma (insulin-producing tumor)
--- Glucagonoma (glucagon-producing tumor)
A. Cholecystitis Clinical Manifestations & Pathophysiological Process :

CLINICAL MANIFESTATION :

Clinical presentation of acute cholecystitis ranges from :
- No physical findings to pain and tenderness in the right upper quadrant (RUQ)
- Sometimes with rebound tenderness
- Guarding
- Fever
- Tachycardia

Pain can be described as colicky pain (intermittent and radiating to the back)
- Related to the movement of gallstones through the bile ducts as the bile flows
- Pain can severe epigastric and in the RUQ with radiation to the back, mid-shoulder/scapula, or in the chest
- Onset is fast
- Commonly within 1 hour of eating a high-fat meal & common at night
- Steatorrhea
- Pain associated with cholecystitis is due to the release of cholecystokinin, which causes the gallbladder to contract
-- Related to the movement of the gallstones through the bile ducts as the bile flows
-- There are several small valves in the ducts & the colicky pain is due to the movement of the stones through these areas
- Radiation to the back is related to the innervations of the gallbladder

- Cholecystitis is difficult to diagnose because not all patients exhibit localized clinical manifestations & pain can be general
- Common for older adults and patients with diabetes to present with vague symptoms...
- 40% of patients have palpable fullness in RUQ & some patients exhibit positive Murphy's sign (pain on palpation of the RUQ upon deep inspiration)
-- Positive Murphy's sign :
--- Examiner's fingers are placed on the RUQ of the abdomen
--- Examiner gently presses down while asking the patient to take a deep breath
--- Test is positive if patient has pain upon deep inspiration
- Some patients with gallstones may be jaundiced because of the impaired bile flow


PATHOPHYSIOLOGY :
Gallstones are hard deposits that form in the gallbladder & are generally classified into three categories :
- Cholesterol stones (the most common type)
- Pigmented (formed from excess bilirubin)
- Mixed stones (combination of both types)

- Gallstones vary in size (pea size → softball size)
- Multiple stones or single stone
- Most commonly found blocking the cystic duct or the common bile duct (choledocholithiasis - gallstones in this location)
- Acalculous cholecystitis - associated with biliary stasis where there is :
-- Slowing or stopping of the flow of bile either from decreased contractility of the gallbladder or spasms in the sphincter of Oddi
-- This sphincter controls the release of digestive enzymes into the duodenum
-- Opening only in response to oral intake
-- When not working properly, it contributes to biliary stasis
-- Exact mechanism of acalculous cholecystitis is not well understood
-- Some believe presence of endotoxin in sepsis can cause :
--- Necrosis
--- Hemorrhage
--- Ischemia to the gallbladder
--- Or that is inhibits the release of cholecystokinin
---- Peptide hormone activated when eating that causes gallbladder to contract and release bile, leading to biliary stasis
- Causes of acalculous cholecystitis :
-- Abdominal surgery
-- Severe trauma
-- Long-term IV nutrition (>1 month)
-- Prolonged fasting
-- Sickle cell disease
-- Diabetes mellitus
-- Endotoxin
-- AIDS
-- Salmonella infection
-- Cytomegalovirus
- Patients with noncomplicated cholecystitis related to gallstones recover within :
-- 1 to 4 days after onset of clinical manifestations
-- And disease has only a 4% mortality rate
- However, approx. 25% of patients with cholecystitis develop a complication :
-- Some requiring emergent surgery (12% of cases)
-- Perforation or gangrene can lead to a critical illness and carry a mortality rate of up to 60%, usually due to sepsis
B. Acute Pancreatitis Clinical Manifestations & Pathophysiological Process :

CLINICAL MANIFESTATIONS :

Patients with acute pancreatitis present with :
- Sudden onset of epigastric pain felt in upper left quadrant or mid-abdomen
- Can radiate to back or shoulder blades
- Pain is usually characterized as being :
-- Deep
-- Very sharp
-- Becomes more intense within minutes of eating foods high in fat content
- Pain can be :
-- Constant & severe
-- Last for several days
-- Some complain of severe pain when lying flat or bending forward
-- Can be associated with :
--- Nausea
--- Vomiting
--- Anorexia
-- Promote bedrest in semi-Fowler's position or fetal position
- General clinical presentation of patients with pancreatitis includes :
-- Abdominal fullness from gas or bloating
-- Hiccups
-- Indigestion
-- Fever
-- Tachycardia
-- Hypotension
- Patients with alcoholic pancreatitis may not have symptoms of pain for several hours or days after binge drinking


PATHOPHYSIOLOGY :

- Acute pancreatitis is the third-leading cause of GI disorders that require hospitalization
-- Cost of care in U.S. for this disease & its complications is more than $2 billion annually
- Reversible process involving inflammation of the pancreas secondary to the release of pancreatic enzymes that "autodigest" the :
-- Pancreas
-- Peripancreatic tissues
-- Adjacent areas
- Autodigestion occurs when pancreatic enzymes digest the pancreas and surrounding tissue
- Acute pancreatitis may occur as :
-- An isolated event
-- Or it may be recurrent
- Exact mechanism of the release of the pancreatic enzymes is not well known & pancreatitis has a variety of causes ranging in severity from mild-severe-life threatening
A. Cholecystitis Diagnosis :

be aware of patient allergies to iodine or radiopaque substances because these may be used for some of the procedures. This includes monitoring for allergic reaction to any diagnostic agent used

- Abdominal x-ray is occasionally used to detect calcified gallstones
- Abdominal ultrasonography
-- Noninvasive test that is commonly used to determine the presence of gallstones and acute cholecystitis
-- Thickened gallbladder is indicative of cholecystitis
- Computed tomography (CT) visualizes the entire abdomen and can detect the presence of gallstones
- The hepatobiliary iminodiacetic acid (HIDA) scan
-- Nuclear medicine scan that uses a radioactive tracer to study :
--- Production and flow of bile
--- Visualizing the
---- Liver
---- Gallbladder
---- Bile ducts
---- Small intestine
- Endoscopic retrograde cholangiopancreatography (ERCP)
-- Allows visualization of the common bile duct where gallstones can be removed
-- In patients with acalculous cholecystitis who are a high operative risk, percutaneous drain can be placed
-- Patients who undergo ERCP :
--- Should not eat or drink anything night before procedure
--- Can take their cardiac and blood pressure medications
--- The morning of of the examination with a small amount of water
-- Sedated for the test and need to have someone drive them home
-- After ERCP :
--- Patient goes to postanesthesia care unit (PACU) to allow time for recovery from sedation
--- Important that nurse observe patient ERCP for potential systemic inflammatory response syndrome (SIRS) caused by manipulation of the bile ducts and potential bacterial translocation
-- Cholangiogram and lab work
--- Commonly used in the operating room to image the biliary tree
--- Radiopaque dye, usually containing iodine, is injected IV, which outlines the bile ducts and gallstones
--- Lab work [CBC & liver function tests] :
---- Elevated WBC due to inflammation
---- Elevated liver enzymes, including :
----- AST
----- ALT
----- Lactate dehydrogenase (LDH)
---- Alkaline phosphatase (ALP)
---- Bilirubin because of blockage of bile flow in the bile ducts
- Cholecystography
-- Rarely used
-- Radiographic test of the gallbladder
-- Patient orally takes radiopaque dye which collects in the gallbladder and is excreted by the liver
- Gallstone in the common bile duct
- Gallstones are most commonly found blocking the cystic duct or the common bile duct
B. Acute Pancreatitis Diagnosis

- Physical examination reveals tender abdomen with localized guarding and rebound tenderness
- Presence of Cullen's sign (periumbilical bruising) and Turner's sign (flank bruising) are infrequent findings and indicate retroperitoneal hemorrhage. Turner's and Cullen's signs usually take 24 to 48 hours to develop and can be predictor of acute pancreatitis with pancreatic necrosis and retroperitoneal or intra-abdominal bleeding
- Laboratory tests -
-- Metabolic panel
-- Glucose
-- Hematology studies
-- Specific tests of pancreatic enzymes such as :
--- Serum amylase
--- Enzyme that aids in the digestion of carbs
-- Serum lipase
--- Enzyme that aids in the digestion of fats
--- Elevated serum lipase is the most specific test for pancreatitis because lipase is produced only by the pancreas
- Rigid or board like abdomen may develop and is generally an ominous sign, usually indicating peritonitis
- Ecchymosis (discoloration of skin resulting from bleeding underneath, typically caused by bruising) in the flank or around the umbilicus may indicate severe pancreatitis

• Albumin --> decreased --> due to poor nutrition
• Amylase --> rapid increase --> pancreatic enzyme
• AST --> elevated --> common in bile flow obstruction
• ALT --> elevated --> common with gallstone pancreatitis
• Calcium --> decreased --> due to fat necrosis, hypoalbuminemia, and malnutrition, all common in alcoholic pancreatitis
• Direct bilirubin --> elevated --> mostly seen with biliary obstruction
• Lipase --> elevated --> pancreatic enzyme
• WBC --> elevated --> due to inflammation

- Elevated BUN :
-- Indicates impaired kidney function suggestive of hypovolemia or hypercatabolic state
-- Monitoring elevations in BUN early in the course of the disease may provide an indicator of mortality from pancreatitis
- Elevated AST :
-- Indicates damage to liver cells
- Elevated ALT :
-- Indicative of gallstone pancreatitis
-- Patients with gallstone pancreatitis may have elevated :
--- Scrum bilirubin
--- Serum amylase
--- Serum liver enzymes :
---- AST
---- ALT
---- ALP
---- LDH
- Related to gallstones obstructing bile flow
Diagnostic imaging tests for pancreatitis :
-- Abdominal CT scans
-- Abdominal magnetic resonance imaging (MRI)
-- Abdominal ultrasound
-- Purpose of these diagnostic tests is to evaluate for the presence of :
--- Inflamed pancreas
--- Gallstones
--- Bile duct obstruction or distention
- Scoring systems to determine severity of pancreatitis :
1. Ranson's criteria
-- Most commonly used
-- Measure severity of illness & likelihood of mortality in patients with pancreatitis
-- Patient is evaluated upon admission and then again within the first 48 hours according to the scoring criteria
-- If at 48 hours, the patient has a score greater than or equal to 3, severe pancreatitis is likely
-- With a score less than 3, severe pancreatitis is unlikely
-- Higher the overall score, the higher the mortality rate


Ranson's Criteria
• age greater than 55 years --> hematocrit decrease greater than 10%
• WBC greater than 16 10^3/mm3 --> BUN increase greater than 5 mg/dL after fluid resuscitation
• LDH greater than 350 IU/L --> calcium less than 8 mg/dL
• AST greater than 250 IU/L --> PaO2 less than 60 mmHg
• Glucose greater than 200 mg/dL --> base deficit than 4 mg/dL fluid sequestration greater than 6 L

Mortality Associated with Ranson's Score
• score 0-2 : 2% mortality
• score 3-4 : 15% mortality
• score 5-6 : 40% mortality
• score 7-8 : 100% mortality

2. APACHE II score (Acute Physiology and Chronic Health Evaluation)
-- Illness severity score calculated on the basis of the first 24 hours of ICU stay
-- Score is based on demographic factors :
--- Age
--- Immunosuppression
--- Chronic health status
-- & physiological factors :
--- Fever
--- Mean arterial pressure
--- Heart rate
--- Oxygen status
--- Serum electrolytes [sodium, potassium, creatinine, hematocrit, WBC count]
--- Glasgow Coma Scale score

3. Balthazar CT severity index
-- Standard for diagnosis of pancreatic necrosis or fluid collections around pancreas & used for scoring severity of pancreatitis
-- Calculated from results of CT scan
-- Ranges from 0 to 10 on a point system given the extent of inflammation :
--- Of the pancreas
--- Surrounding pancreatic tissue
--- Presence of pancreatic necrosis
-- Grading between A through E, representing range from normal pancreas → inflammatory changes → peripancreatic fluid collections
-- Necrosis of the pancreas is scored based on the percentage of the pancreas with necrosis with an overall higher percentage correlating with a higher severity of illness and poor outcome

4. Bedside Index Severity of Acute Pancreatitis (BISAP)
-- Score is calculated based on several patient factors :
--- Age
--- Mental status
--- BUN
--- Presence of pleural effusions
--- SIRS criteria (points for fever range, respiratory status, WBC)
-- Score of 0 to 2 indicates a mortality rate of <2%
-- 3 to 5 points is associated with a mortality rate of >15%
Cholecystitis Treatment & Management :

Diet :
- Restrict fatty foods because they promote gallstone formation :
-- Fried foods
-- Ice cream
-- Dairy products
-- Red meats
-- Heavy alcohol
-- Low fat diet
- Choose foods low in saturated fats including :
-- Rice
-- Potatoes
-- Pasta
-- Yogurt
-- Fruits
-- Lean meat
-- Whole grains

Treatment :
- Used to be treated with extracorporeal shock wave therapy or lithotripsy
-- Used to dissolve gallstones
-- Patients would sit in a tube of water & high-energy shock waves were directed through the water toward the stones to break them up into smaller pieces that would then pass through the bile duct
-- Used in conjunction with oral agents to help dissolve the gallstones
-- Lithotripsy is used for treatment of small gallstones
-- Current preferred method of intervention for gallstones is laparoscopic surgery
-- refer to page 1, includes details for medical management

Nursing Management -
Assessment & Analysis :
- Most common symptom of acute cholecystitis → abdominal pain
-- Colicky pain → intermittent and radiating to the back
- Physical examination includes :
-- RUQ tenderness
-- Fever
-- Elevated heart rate
- Upon physical examination, patient may have :
-- Positive Murphy's sign
-- Elicited during deep palpation of the abdomen
-- Pain occurs when the inflamed gallbladder touches the peritoneum during deep inspiration
-- Not unusual for patients to quickly hold their breath or stop breathing when they experience the pain from this test
- Patients also have :
-- Elevated liver enzymes
-- Bilirubin
-- WBC
-- Because of obstruction and inflammation

Nursing Diagnoses :
- Acute pain related to obstruction and edema related to gallstones
- Fluid volume deficit related to nausea, vomiting, and increased insensible fluid loss
- Imbalanced nutrition, less than body requirements, related to nausea and vomiting
- Knowledge deficient regarding condition, prognosis, treatment regimen, self-care, and discharge needs

Nursing Interventions :
Assessments :
- Vital signs :
-- Fever and tachycardia may represent inflammation due to gallstones. Elevated respiratory rate may occur because of anxiety and pain, the rate may be shallow and rapid because of pain, and blood pressure may be low as a result of dehydration/inflammatory response
- Serum electrolytes :
-- These measure imbalance electrolytes due to dehydration from nausea and vomiting and lack of oral intake and include BUN and creatinine (elevated). In the patient with nasogastric tube suctioning, the serum potassium should be monitored closely because this electrolyte is lost with nasogastric suctioning
- Serum WBC :
-- Inflammation leads to an elevated WBC count
- Liver enzymes, bilirubin :
-- Liver enzymes (AST, ALT, LDH, ALP) and bilirubin are elevated because of blockage of bile flow in the bile ducts
- Skin turgor :
-- Decreased skin turgor indicates dehydration
- Pain (onset, duration, exacerbating and relief factors) :
-- Pain can be intermittent and colicky. Pain can be severe epigastric and in the RUQ with radiation to the back, mid-shoulder/scapula, or in the chest. The onset is fast, commonly within 1 hour of eating a high-fat meal, and common at night
- Abdominal assessment : distention, bowel sounds ; Murphy's sign :
-- Palpation may reveal rebound tenderness, muscle guarding, or rigid abdominal muscles due to pain
- Stool :
-- Steatorrhea (presence of excess fat in stool or oily stools), clay-colored stools due to blockage of bile flow
- Daily weight :
-- Provides information in regard to fluid gains or losses
- Intake and output :
-- Provide data about fluid volume status and prevention dehydration
- Nutritional intake :
-- Determines diet history, fat intake, foods that can contribute to symptoms

Actions :
- Maintain NPO status :
-- NPO status prevents gallbladder contraction that releases bile to break down nutrients; these contractions cause pain because of the inflamed gallbladder
- Administer ordered antibiotics :
-- A short course of antibiotics may be given to reduce inflammation and treat infection
- Administer ordered bile acid reducers :
-- Bile acid reducers help dissolve gallstones
- Administer analgesics as ordered :
-- Analgesics decrease the patient's symptoms of pain. Avoid morphine due to spasm of the sphincter of Oddi
- Administer antiemetics as ordered :
-- Antiemetics decrease symptoms of nausea and vomiting, which may occur for a prolonged time due to abdominal pain and obstruction
- Promote bedrest in semi-Fowler's position :
-- Avoid lying flat because this makes the pain worse, particularly with peritonitis, by stretching the abdominal muscles when supine. Repositioning helps alleviate abdominal pain and pressure
- Nasogastric tube (NGT) to low suction (intermittent or continuous is ordered based on type of tube)
-- An NGT is used to decompress the stomach and remove gastric secretions

Teaching :
- Postoperative instructions :
-- Discharge teaching includes :
--- Signs & symptoms of infection
--- Prevention of constipation
--- Low-fat diet
--- Activity restrictions (encourage walking and normal activity within a week, such as driving, working, and light lifting of less than 10 pounds) and no driving while taking narcotics
- T-tube management :
-- Patient needs to monitor the insertion site for inflammation and drainage. T-tube bag should be emptied when ½ to ⅔ full to decrease the pull on the insertion site
- Patient should avoid a diet high in saturated fats :
-- Abstaining a diet history can help identify foods that contribute to symptoms
-- Bile breaks down fats; thus, a diet high in fat requires activation of bile for breakdown and increases pain
-- Stress small, frequent meals
- Disease clinical manifestations, progression, diagnostic procedures, and interventions :
-- Patient education about the disease improves overall management and health. It is important that the patient recognize and report symptoms that may indicate relapse or complications, including pain, chills, fever, jaundice, dark urine, and light (clay-colored) stools
B. Acute Pancreatitis Treatment & Management

Diet :
- Patients with severe acute pancreatitis are managed with :
-- IV fluids
-- Parenteral nutrition
-- Avoiding use of enteral nutrition in an effort to "rest" the inflamed pancreas and prevent the release of pancreatic enzymes
-- However evidence of early initiation of enteral feedings helps protect the GI mucosal barrier, but optimal timing and formulations require more study
-- Patients with mild forms of acute pancreatitis usually begin oral intake within few days of their first onset of pain and do not require parenteral nutrition
- All oral intake is withheld to inhibit stimulation of the pancreas and its secretion of enzymes. NPO....
- Parenteral nutrition plays an important role in the nutritional support
- If pancreatitis is caused by gallstones, the patient may undergo cholecystectomy, follow up with healthcare provider
- The acutely ill patient is maintained on bed rest to decrease the metabolic rate and reduce the secretion of pancreatic and gastric enzymes
- Endoscopic Retrograde Cholangiopancreatography/ERCP
-- Visualization of pancreatic and biliary ducts
-- Technique that combines the use of endoscopy and fluoroscopy to diagnose and treat certain problems of the biliary or pancreatic ductal systems
- Patients are given :
-- IV hydration
--- Includes several liters of fluid initially followed by a high rate of maintenance fluid at approximately 200 to 300 mL/hr continuously to maintain intravascular volume
--- Crystalloids, either Normal Saline or Lactated Ringer's are the most common fluids used
--- Some evidence suggest that a combo of crystalloids & colloids should be used
--- If patient receives several liters of IV fluid, it is imperative to monitor the patient for clinical manifestations of overhydration that can lead to pulmonary edema
-- Pain medications
- If patient has severe acute pancreatitis with end-organ involvement (heart, lungs, kidneys) :
-- Patient needs to be managed in ICU because of potential for :
--- Hypovolemic shock
--- Pulmonary compromise
--- Renal failure
--- GI bleeding
-- Aggressive supportive therapy is crucial to the recovery of these patients because they may require medications to decrease inflammation & surgical procedures to resect areas of necrotic pancreas
- In general, IV antibiotics are not given to patients with acute pancreatitis related to fever because :
-- The fevers are secondary to inflammation of the pancreas, not infection
- If patient has necrotic pancreatitis :
-- IV antibiotics are indicated
- If pancreatitis is caused by gallstones :
-- Patients generally undergoes cholecystectomy
- Specific cause of pancreatitis (biliary obstruction, alcohol) also determines medical management :
-- Gallstone-induced pancreatitis leads to :
--- Removal of gallbladder (cholecystectomy) for acute treatment & to prevent recurrence of pancreatitis
--- Laparoscopic cholecystectomy is performed if patient is stable & inflammation has resolved
--- Endoscopic sphincterotomy to dislodge gallstones may alternatively be performed
---- Endoscope is placed into the ducts in the opposite direction of bile flow
---- Sphincter or muscles of the bile and pancreas are cut to remove gallstones or blockages
Usually done after an ERCP
-- Alcohol induced pancreatitis :
--- Important to monitor and treat patient for alcohol withdrawal with includes :
---- Agitation
---- Hallucinations
---- Tachycardia
---- Fever
---- Diaphoresis
---- Possible nausea and vomiting
--- Treatment may include :
---- Sedation
---- Hydration
---- Nutrition

Medications :
- Opioid analgesics for pain
- Anticholinergics to decrease secretions
- Histamine blockers
- Pancreatic enzymes
- Antibiotic therapy

• opioid narcotics : morphine sulfate --> treats pain
• anticholinergic agents --> decreases intestinal motility and decrease pancreatic enzyme release
• spasmolytics --> relaxes smooth muscle and relax sphincter of Oddi
• H2 (histamine) antagonist or proton pump inhibitor --> decreases gastric acid secretions
•Pancreatic enzymes --> aids in digestion of fats and proteins, taken with meals
• antibiotics --> treats acute necrotizing pancreatitis
• octreotide --> decreases secretion of enzymes

- Prophylactic antibiotics for acute pancreatitis have been controversial for the last five decades
-- Some studies have suggested that there is a lower incidence of peripancreatic infection with the use of antibiotics
-- However, routine use of antibiotics as prophylaxis against infection in severe acute pancreatitis is not recommended
-- Because mortality associated with pancreatitis is primarily due to infectious complications, use of antibiotics for this disease has been common, but evidence does not support routine antibiotic use because no difference in outcome was found between patients treated with antibiotics versus those who received a placebo
-- If antibiotics were utilized, it is important that antibiotics chosen penetrate the pancreatic tissue to treat the infection

Nursing Management -
Assessment & Analysis :
- Classic presentation of acute pancreatitis is the sudden onset of acute unbearable abdominal pain. Other common clinical manifestations include :
-- Elevated heart rate and respiratory rate, and low blood pressure
-- Pain
-- Elevated serum lipase, amylase, and glucose values
-- Hypocalcemia
-- Steatorrhea, clay-colored stools
-- Hypovolemia
-- Hypoxia
-- Pleural effusion
-- Clinical manifestations of Adult Respiratory Distress Syndrome (ARDS)
-- Multiple organ dysfunction
- Abnormal vital signs include :
-- Tachycardia & hypotension due to intravascular volume depletion
-- Patients have elevated third-space volume loss due to capillary leak or loss of fluid into the interstitial space and out of the intravascular spaces
-- This volume loss requires IV fluid resuscitation
-- If volume loss not replenished, patients can develop shock and multiple organ dysfunction
- Lab analysis shows :
-- Elevated liver enzymes and bilirubin, along with elevated WBC count
-- Calcium levels are low because of accumulation of fatty acids, which chelate calcium salts, causing soapy deposits in the abdomen.
- Stools are clay colored due to the blockage of bile into the duodenum
- Hypoxia occurs because :
-- Intrapulmonary shunting caused by collapsed of small alveoli in the dependent airways, whereby blood in the pulmonary system is not ventilated, and no gas exchange occurs
- Typical to see patient with pancreatitis have room air PaO2 <75 mmHg (normal PaO2 → 80-95 mmHg)
- Respiratory insufficiency can lead to acute respiratory distress syndrome (ARDS)
-- Complication that leads to mortality rate of more than 50%
-- ARDS is an acute lung injury caused by inflammation of the lungs, causing stiffness and the inability to exchange oxygen

Nursing Diagnosis :
- Acute pain related to inflammation, edema, and distention of the pancreas and surrounding tissue
- Ineffective breathing pattern related to pain, pulmonary infiltrates, pleural effusion, and atelectasis
- Imbalanced nutrition, less than body requirements, related to decreased food intake and increased metabolic demands

Nursing Interventions :
Assessments :
- Vital signs :
-- Fever and tachycardia may represent inflammation. An elevated respiratory rate may occur because of anxiety and pain, the rate may be shallow and rapid as a result of pain, and blood pressure may be low because of dehydration and fluid shifts secondary to the inflammatory response
- Oxygen status :
-- The patient's PaO2 may be decreased because of alveoli collapse and pleural effusion
- Pain location, intensity, duration :
-- Pain located in the RUQ (head of pancreas) or LUQ (tail of pancreas) is related to autodigestion of the pancreas due to leaking of pancreatic enzymes into tissue surrounding the pancreas, leading to edema, distention of the pancreas, and peritoneal irritation. Localized pain may indicate pseudocyst or abscess formation
- Abdominal assessment :
-- Palpation may reveal rebound tenderness, muscle guarding, or rigid abdominal muscles
- Bulletblue Turner's and/or Cullen's signs :
-- Bulletblue Turner's sign is bruising noted on the flank due to leaking of exudate stained with blood into the flank area ; Cullen's sign is bruising around the umbilicus. Bruising in these areas indicates hemorrhage, severe inflammation, and tissue damage
- Serum lipase and amylase :
-- Elevated lipase and amylase are due to inflammation of the pancreas, which interrupts its normal structure and function. Serum lipase levels are a useful diagnostic biomarker in pancreatitis because levels can remain elevated for up to 2 weeks. Elevated amylase levels that are three times normal are indicative of acute pancreatitis. These levels are elevated within 12 hours of the onset of inflammation, and elevation can last approx. 4 days
- Serum glucose :
-- Glucose elevations due to the digestion of the pancreas, which leads to decreased production and availability of insulin
- Serum calcium, Trousseau sign, or Chvostek sign :
-- Hypocalcemia : assess for neuromuscular irritability when calcium levels are low because of the accumulation of fatty acids, which chelate calcium salts, causing soapy deposits in the abdomen
-- Trousseau sign : hand spasms with inflation of the blood pressure cuff 20 mmHg above the patient's systolic blood pressure (SBP) for 3 to 5 minutes. Under these ischemic conditions, the nerves become irritable, and spasms result
-- Chvostek sign : facial twitching. Tapping the skin over the facial nerve anterior to the external auditory meatus produces Chvostek sign. In a patient with acute hypocalcemia, ipsilateral contraction of the facial muscles occurs
- Stool color :
-- Steatorrhea, clay-colored stools due to obstruction of bile flow
- Nutritional intake :
-- Patients exhibit loss of appetite because of pain ; in alcoholic pancreatitis, patients may be malnourished at baseline
- Daily weight, monitoring of fluid intake and output :
-- Daily weights and intake and output monitor fluid volume status and prevent dehydration. Hypovolemia (intravascular) occurs because of third-space losses in the retroperitoneum from autodigestion of the pancreas and capillary leak ; these fluids shifts can impact weight, and with significant ascites formation, the weight increases as the fluid retention increases

Actions :
- Maintain NPO status :
-- Maintaining NPO status decreases the secretion of digestive enzymes and prevents the contraction of the gallbladder and the release of cholecystokinin
- NGT to low suction, as ordered :
-- Decompresses stomach, prevents abdominal distention
- Administer ordered medications :
- Administer analgesics :
-- Analgesics decrease the patient's symptoms of pain
- Administer antiemetics :
-- Antiemetics decrease symptoms of nausea & vomiting, which may occur over a prolonged time
- Administer histamine blockers :
-- Histamine blockers to decrease acid secretion and inhibit pancreatic enzyme activity
- Administer sedatives and anti-anxiety medications :
-- Sedative and antispasmodics help decrease spasms and subsequent enzyme secretions
- Promote bedrest in semi-Fowler's position or fetal position :
-- Bedrest decreases the stimulation of pancreatic secretions and resulting pain. The semi-Fowler's position relieves abdominal pressure and tension, and the fetal position is generally most comfortable
- Encourage coughing and deep breathing :
-- These help to prevent atelectasis and improve oxygenation
-- Patients commonly have pleural effusions

Teaching :
- Appropriate diet and intake of small, frequent meals and vitamin supplements :
-- A diet history can help identify foods that can contribute to symptoms. Oral intake should be limited initially to small amounts (fist-sized) and then slowly advanced as the pain subsides. Decreased pain is an indicator of decreased inflammation. Initial foods to eat after an illness with pancreatitis include carbohydrate-containing foods because they stimulate the pancreas less. Avoid fat- and protein-rich foods, which increase pancreatic enzyme stimulation
- Abstain from alcohol :
-- Alcohol consumption accounts for approx. ⅓ of all cases of pancreatitis
- Abstain from smoking :
-- Smoking is associated with pancreatic cancer and with interfering with the healing needed by the pancreas; smoking can be adversely impact the healing process
- Disease symptoms, progression, diagnostic procedures, and interventions :
-- Patient education about the disease improves overall management and health and provides details that the patient needs to report to the healthcare provider

Evaluating Care Outcomes :
- Pain management and nutritional status are indicators of how the disease is progressing
- Positive outcomes of acute pancreatitis include :
-- Stable vital signs
-- Stable weight
-- Serum electrolytes WNL
-- Decreased pain
-- Decreases in liver enzymes
C. Chronic Pancreatitis & Management

Treatment :
- Pain management
- IV fluid replacement
- Electrolyte management
- Nutritional support
- Insulin therapy to treat elevated blood glucose levels
- Pancreatic enzyme replacement therapy (PERT) :
-- Used to treat malnutrition and malabsorption associated with chronic pancreatitis and provides :
--- Amylase
--- Lipase
--- Protease
- Many cases are cared for in the ICU
-- GI prophylaxis with histamine blockers or proton pump inhibitors may be prescribed secondary to increased gastric acid secretion
- Patients with significant weight loss secondary to this disorder :
-- Total parenteral nutrition may be required
-- Patient education on modification of :
--- Heavy tobacco use
--- Alcohol consumption

Surgical Management :
- Surgical resection may provide symptomatic relief of pain
-- Surgical intervention is not always appropriate because risk are high
- Surgical procedure for pain relief :
-- Puestow procedure :
--- Opens the pancreatic ducts and redirects the flow of pancreatic enzymes into the intestine or resection of the head of the pancreas
-- Laparoscopic draining :
--- Indicated in patients with abscesses or pseudocysts
- Because of the irreversible nature of chronic pancreatitis, these surgical procedures address issues related to :
-- Pain
-- Inflammation
-- Obstruction
-- Are not curative

Nursing Management -
Assessment & Analysis :
- Characterized by pain & weight loss & is an irreversible disease process
- In addition to constant, burning pain that is characterized by exacerbations of intense, unrelenting pain, other clinical manifestations include :
-- Anorexia
-- Nausea & vomiting
-- Constipation
-- Flatulence
-- Steatorrhea (fatty stools)
-- Elevated amylase, lipase, serum bilirubin, and alkaline phosphatase
-- Elevated blood glucose levels

Nursing Diagnoses :
- Acute Pain related to inflammation and obstruction of the pancreas
- Imbalanced nutrition, less than body requirements, due to malabsorption and altered secretion of pancreatic enzymes
- Hopelessness related to the chronic, progressive, irreversible nature of chronic pancreatitis

Nursing Interventions :
Assessments :
- Vital signs :
-- Pulse rate, respiratory rate, and blood pressure elevations are associated with episodes of pain exacerbations
- Serum blood glucose levels :
-- With decreased insulin production/release with endocrine dysfunction, serum glucose levels are elevated
- Amylase and lipase levels :
-- Elevations of these pancreatic enzymes are associated with chronic pancreatitis
- Serum bilirubin and alkaline phosphatase :
-- Obstruction of the bile ducts leads to increases of both bilirubin and alkaline phosphatase
- Weight :
-- Because of malabsorption secondary to the altered secretion of pancreatic enzymes, the patients with chronic pancreatitis is at risk of weight loss
- Pain :
-- Chronic pancreatitis is characterized by persistent, recurring episodes of epigastric and LUQ pain secondary to inflammation and obstruction
- Abdomen :
-- Tenderness of the abdomen may be observed. Palpation may reveal a mass in the LUQ that may indicate a pseudocyst or abscess
- Skin color :
-- Jaundice may be observed with obstruction of the bile ducts
- Stool :
-- Steatorrhea may develop with progressive pancreatic insufficiency, as well as clay-colored stools with bile obstruction

Actions :
- Administer pancreatic enzymes (PERT) :
-- These medications contain amylase, lipase, and protease to enhance the absorption of nutrients
- Provide GI prophylaxis as ordered :
-- Histamine blockers or proton pump inhibitors may be prescribed to treat the increased gastric acid secretion associated with chronic pancreatitis
- Provide rest and a calm environment :
-- These interventions decrease strain on the already-diseased pancreas and may decrease the secretion of acids in the stomach, which can exacerbate chronic pancreatitis
- Implement pain-relief measures :
-- Pain may be managed with the administration of opioids initially and then with nonopioids when the pain is less intense
- Collaborate with a dietitian to ensure adequate nutrition :
-- The patient may require increased caloric intake or parenteral nutrition as a result of alterations in absorption. A low-fat diet is often prescribed because of difficulty breaking down fats, resulting in steatorrhea

Teaching :
- Avoid alcohol :
-- Alcohol further exacerbates the dysfunction of the pancreas
- Do not chew pancreatic enzymes :
-- These medications are available as extended-release or enteric-coated formulations, so they need to be swallowed whole to receive a therapeutic dose
- Limit fat in the diet :
-- Malabsorption of fat is associated with chronic pancreatitis, and fat is limited in the diet, particularly in patients with steatorrhea
- Avoid intake of irritating foods/beverages (coffee, caffeine)
-- This may increase gastric distress
- Referral to support groups such as Alcoholics Anonymous or Al-Anon :
-- Chronic pancreatitis is a progresssive, irreversible disease, and avoiding the use of alcohol minimizes further damage to the pancreas. Additionally, participation in support groups may be therapeutic and may provide suggestions and recommendations for dealing with this chronic disorder
D. Pancreatic Cancer Treatment & Management

Treatment :
- Radiation
-- External beam radiation to the tumor and surrounding tissue over a 6-week period
- Chemotherapy
-- 5-fluorouracil chemotherapy for up to 4 months
- Surgical resection is potentially curable
-- Only a small percentage of patients qualify for surgical resection because of the latent nature of the clinical presentation
- If cancer has spread to distant lymph nodes or there is metastasis to the liver, cancer is generally unresectable
-- Patients may undergo surgery to relieve symptoms (palliative surgery), but excision of the tumor is not possible
- Celiac nerve block can be performed to decrease pain associated with the tumor's compression of the celiac nerves surrounding the aorta
- If tumor is located in the :
-- Head
-- Neck
- Uncinate process of the pancreas
-- Patient can undergo Whipple procedure or pancreaticoduodenectomy
-- Head of pancreas
-- Distal stomach
-- Spleen
-- Gallbladder
-- Common bile duct
-- Portions of the duodenum
-- Proximal jejunum
-- Lymph nodes
-- Are resected
- If tumor is in the body or tail of pancreas, patient undergoes :
-- Distal pancreatectomy (removal of the tail and part of the body of the pancreas) and splenectomy
- Pancreaticojejunostomy → anastomosis of the pancreas to the jejunum
- Hepaticojejunostomy → anastomosis of the hepatic duct to the jejunum
- Gastrojejunostomy → anastomosis of the stomach to the jejunum
- Above three may also be done to reconstruct GI tract
- Vagotomy → surgical resection of the vagus nerve
-- Done to decrease acid secretion in the stomach and decrease peptic ulcer formation

Post-Op :
- Monitor for exocrine insufficiency (lack of digestive enzymes to properly digest food) & insulin-dependent diabetes mellitus
- In addition, patients will have an NGT that is not to be manipulated
-- NGT are not to be repositioned, irrigated, or checked for placement because these actions can cause a breakdown of the anastomotic site
-- If patient removes the NGT, it is not to be replaced by nursing staff
- Pain management via PCA
- Pulmonary interventions to encourage lung expansion
- Coughing and deep breathing to prevent pneumonia & atelectasis
- Abdominal assessment

Nursing Management -
Assessment & Analysis :
- Present with nonspecific clinical manifestations that can be attributed to a variety of GI disturbances
- Primary clinical manifestations :
-- Pain
-- Jaundice
-- Fatigue
-- Anorexia
-- Weight loss
- With vague, nonspecific abdominal & epigastric pain common
- Pain is described as dull and intermittent that sometimes increases in intensity with eating & movement
- Jaundice
-- Occurs in 80% of patients
-- Develops in a pattern that is first seen in the mucous membranes
-- Then palms of hands
-- Eventually becomes generalized
- Patients may complain of pale, greasy stools, which is attributed to a tumor that blocks digestive enzyme release
- Pruritus (itchy skin caused by dry skin) starting with the palms of hands and then generalized
- Dark-amber urine due to accumulation of bilirubin

Nursing Diagnoses :
- Pain : acute or chronic related to the pressure caused by the pancreatic mass
- Imbalanced nutrition : less than body requirements related to malabsorption and anorexia
- Anxiety related to the cancer diagnosis

Nursing Interventions :
Assessments :
- Vital signs :
-- Tachycardia may be related to fever and pain. Elevated blood pressure may be related to pain and anxiety. Fever may be related to infection due to blocked bile ducts
- Fluid intake & output :
-- Daily intake and output monitor fluid volume status and prevent dehydration. With the development of ascites, there may be a fluid shift from the intravascular space
- Serum glucose :
-- Elevated because of impaired insulin secretion due to tumor or due to removal of pancreas, which secretes insulin
- Weight :
-- Weight loss due to anorexia due to presence of tumor and malabsorption
- Muscle mass :
-- Cachexia (weight loss) secondary to loss of muscle mass is common because of decreased appetite and altered protein metabolism
- Pain location, intensity, duration :
-- It is important to note the location, intensity, and duration of pain that is caused by the pancreatic tumor compressing surrounding organs and nerves. Pain may radiate to the back because of the compression of nerves
- Abdomen :
-- Distention and enlargement of the abdomen are common in advanced disease because of the presence of ascites
- Skin color :
-- Jaundice due to tumor obstruction of bile flow
- Pruritus :
-- Accumulation of bile salts under the skin causes itching
- Postoperative assessment :
-- Postoperatively monitor vital signs, pain, glucose, NGT output, abdominal assessment, and surgical site

Actions :
- Provide IV fluids :
-- Hypovolemia occurs because of third-space losses in the retroperitoneum from autodigestion of the pancreas and capillary leak
- Maintain NPO status :
-- Maintain NPO status until the return of GI function postoperatively, then slowly introduce a diet with clear liquids, and then advance to a regular diet to decrease strain on the surgical site
- NGT to low suction :
-- Decompresses stomach because postoperative abdominal distention and decreased GI tract motility can place strain on the surgical anastomosis
- NEVER manipulate NGTs :
-- NGTs are placed by the surgeon, and manipulation can increase the risk of anastomotic breakdown
- Administer insulin :
-- Pancreatic cancer affects the ability of the pancreas to produce and secrete insulin, leading to hyperglycemia
- Encourage coughing and deep breathing and the use of an incentive spirometer or flutter valve every hour while awake :
-- Prevents atelectasis, improves oxygenation, prevents postoperative pneumonia
- Administer analgesics and antiemetics as ordered :
-- Pain management postoperatively for incisional pain and discomfort; preoperative pain management for pain caused by tumor compression
- Nutritional supplements :
-- These help improve calorie input, prevent weight loss, and promote postoperative surgical wound healing. These include high-calorie, high-protein supplements

Teaching :
- Postoperative care : what to expect after surgery, pain management :
-- Informs the patient and improves compliance with prescribed interventions
- Medication regimens :
-- It is important for the patient to be knowledgeable of the mechanism of actions as well as the side effects of the ordered medications. Pain medications may increase the risk of constipation and increase pressure and discomfort in the abdominal cavity
- Diet & nutrition :
-- Nutritional supplements are prescribed to increase calorie intake to maintain weight and promote healing after surgery. Megestrol acetate (Megace) may be given as an appetite stimulant
- Signs & symptoms of hyperglycemia and hypoglycemia :
-- With compression and damage to the pancreas, the production and secretion of insulin and glucagon may be impaired, leading to hyperglycemia or hypoglycemia
- Disease symptoms, progression, diagnostic procedures, and interventions :
-- Patient education about the disease and disease progression improves symptom management and increases compliance with the prescribed interventions
- Coping skills, palliative care, and support groups :
-- Support groups and networks provide additional information for patient and family
Stomatitis - Medical Management

- Prompt diagnosis through frequent assessment of oral cavity, before, during, and after chemotherapy & radiation therapy
- Preventative measures :
-- Oral mouth rinses every 4 hours or more frequently
-- At bedtime using solution of 1 teaspoon of salt or sodium bicarbonate (baking soda) per pint of water
-- Or saline & sodium bicarbonate mixture
- Benefits of oral rinses :
-- Removal of loose particles and hydration of oral tissue
-- Sodium bicarbonate thins oral mucus and decreases acidity and yeast growth
- Topical analgesics & anesthetics may be prescribed to :
-- Relieve lip or mouth pain
-- Moisturizers should be applied to the lips and oral membranes as needed to prevent dryness and cracking
- Patients are encouraged to see dentist for thorough oral cleaning and examination at least 1 month prior to chemotherapy or radiotherapy in order to prevent oral cavity complications

Complications :
- Increased risk for :
-- Pain because of inflammation & ulcerations of the oral mucosa
- Due to painful ulcerations in mouth, they may demonstrate :
-- Dysphagia (difficulty swallowing)
-- Odynophagia (painful swallowing)
- Patients who are unable to eat require parenteral or enteral feedings to maintain nutritional requirements
- In severe cases of stomatitis :
-- Open lesions
-- Edema
-- May result in airway obstruction as well as oral and systemic infections with the spread of bacteria, viruses, and other infectious agents
- Stomatitis interrupts function & integrity of oral cavity, which affects quality of life
- Patients may experience interruptions in treatments & dose adjustments related to :
-- Mucotoxic side effects of therapies
-- Thus affecting therapeutic outcomes in patients receiving radiation & chemotherapy

Oral Stomatitis Grading Scale
- Functional/symptomatic
-- Grade 1
--- able to eat a normal diet with minimal symptoms
-- Grade 2
--- symptomatic but can eat a modified diet
-- Grade 3
--- symptomatic and unable to eat or drink by mouth
-- Grade 4
--- symptoms are life threatening
-- Grade 5
--- Death
- Clinical examination
--Grade 1
--- redness of mucosa
-- Grade 2
--- patchy oral ulcerations
-- Grade 3
--- confluent oral ulcerations that bleed with minor trauma
-- Grade 4
--- tissue necrosis with significant bleeding; life-threatening consequences
--Grade 5
--- Death

Stomatitis - Nursing Interventions - Teaching :
Nursing Interventions :
- Vital signs :
-- Temperature may be elevated if there is infection associated with stomatitis. Fluid volume deficit may lead to increased pulse rate and decreased blood pressure
- Oral mucosa :
-- Bleeding or ulcerated oral mucosa occurs from a number of causes including :
--- Nutritional deficiencies
--- Exposure to radiation
--- Chemotherapy
--- Irritants
--- Allergic responses
--- Pathogenic organisms
--- Assessing the cause and severity of the oral mucosa impairment determines the treatment plan
- Nutritional intake :
-- Patients with painful oral lesions avoid eating and drinking and experience dysphagia and weight loss
- Weight :
-- Due to pain in the mouth and difficulty swallowing, the patient may have insufficient caloric intake to maintain an ideal weight
- Intake and output :
-- Fluid intake may be compromised due to oral ulcerations as well as difficulty swallowing

Actions :
- Implement aspiration precautions :
-- Viscous lidocaine can decrease the gag reflex for a short period of time. Suction equipment should be in place, and the head of the bed (HOB) should be elevated at least 45 degrees
- Administer prescribed medications :
-- Antimicrobials (antibiotics, antifungals, topical and immune modulators) are used to treat stomatitis-related infections
-- Antimicrobials : tetracycline syrup and minocycline swish and swallow
--- Topical and oral antimicrobial medications provide systemic and topical therapy for relief of infection-related symptoms
-- Antiviral medications : acyclovir (Zovirax) IV and acyclovir PO/topical
--- For herpes simplex stomatitis, IV acyclovir (Zovirax) is given to patients who have impaired immune function. Patients with intact immune function may receive acyclovir in topical or oral form
-- Antifungal medications : nystatin ice pop or troche (lozenge)
--- Nystatin (Mycostatin) swish-and-swallow suspension provides both local and topical applications
-- Viscous lidocaine, Campho-Phenique mouthwash, triamcinolone in benzocaine (Kenalog in Orabase) topically, and with dexamethasone elixir : swish and expectorate
--- For relief of local discomfort, viscous lidocaine, topical triamcinolone in benzocaine (Kenalog in Orabase), and dexamethasone elixir are used to swish and expectorate and are often used for RAUs. other medications used for the treatment of RAUs include antibiotics, multivitamins, low-level laser therapy (LLLT), and a variety of combined therapies
-- Administer water-soluble lubricants for the lips and mouth :
--- Lanolin-based creams and ointments are most effective for moisturizing and softening dry, chapped lips

Teaching :
- Mouth care after each meal and as needed, using a soft-bristle toothbrush :
-- Frequent gentle mouth care cleanses the mouth of pathogens and prevents further infection
-- Frequent mouth rinsing with warm saline or sodium bicarbonate (baking soda) solution promotes comfort and gentle cleansing and rinses pathogens from the oral cavity
- Discourage the use of alcohol-containing mouthwash and lemon-glycerin swabs :
-- Mouthwashes containing alcohol can further dry and irritate the oral mucosa, and lemon-glycerin swabs can irritate sore, inflamed oral tissue
- Dentures and other oral appliances should be removed if patient experiences severe stomatitis or oral pain :
-- Dental appliances can cause irritation and ulcerations of oral tissues and increase the risk of infection. Dentures should not be worn if oral injury exists. Daily cleaning with a commercial denture cleaner, brushing, and rinsing after each meal to prevent colonization of pathogenic organisms and infection
- Encourage regular dental checkups :
-- Dental examinations provide thorough cleaning and expert assessment of the oral cavity to screen for complications and pathology
- Encourage saline mouth rinses every 4 hours and as needed :
-- A dry mouth puts patients at risk for oral complications
- Dietary choices influence pain and healing :
-- Foods and fluids that are high in protein or vitamin C promote healing. Foods that cause irritation are those that are spicy, salty, hot, hard, and acidic and have sharp edges
Gastroesophageal Reflux Disease - Nursing Interventions - Actions & Teaching

Nursing Interventions :
Assessments :
- Respiratory symptoms : aspiration pneumonia, chronic cough, morning hoarseness, night-time wheezing, adult-onset asthma, laryngitis, pharyngitis, bronchitis with long-term regurgitation :
-- Respiratory symptoms occur with aspiration of acid reflux into the tracheobronchial tree, larynx, pharynx, nose, and mouth (especially when supine). GERD is a causative factor in the development of adult-onset asthma
- Regurgitation :
-- Occurs when acid reflux reaches the level of the pharynx, leaving a sour taste in the mouth. If the patient is supine, regurgitation can lead to aspiration
- Severe atypical chest pain :
-- Caused by esophageal spasms or stimulation of esophageal pain receptors. Pain may be so severe that it lasts for 2 horus, and it can radiate to the neck. Pain increases when supine, bending, or performing a Valsalva. The etiology of chest pain needs to be determined to rule out cardiac causes
- Hemorrhage :
-- Associated with erosion and necrosis of the esophagus from chronic acid reflux
- CBC :
-- Chronic erosion of the esophageal tissue may lead to bleeding that results in decreased hematocrit and hemoglobin
- Dyspepsia :
-- Reflux of gastric contents into the esophagus occurs most often as a result of excessive relaxation of the LES, leading to inflammation and ulceration of the esophagus. Minor bleeding from capillaries may occur with erosion
- Dysphagia and odynophagia :
-- The damage from the refluxate causes inflammation and ulcerations in the esophagus. When healing occurs, scarring occurs with the development of strictures or rings, causing esophageal stenosis and difficulty swallowing
- Signs of Barrett's esophagus :
-- Metaplasia of columnar epithelium from squamous cells in the lower third of the esophagus results from chronic acid reflux into the esophagus. Columnar cells, like the cells found in the stomach, are resistant to the damaging effects of stomach acid ; however, these cells, not normally seen in the esophagus, have a propensity for dysplasia, thus becoming adenocarcinomas
- Dental caries :
-- Eructation of acid reflux into the oral cavity leads to the destruction of tooth enamel and decay
- Water brash :
-- A production of excessive saliva in response to reflux, leading to the sense of fluid in the throat, is termed water brash. There is no sour taste, and acid is not present. Patients who exhibit water brash may or may not have esophageal injury
- Eructation, flatulence, or bloating :
-- Occurs when eating a large meal and with abdominal distention, causing increased intra-abdominal pressure. The LES pressure decreases and allows gastric refluxate to enter the esophagus
- Nausea :
-- Nausea occurs as a result of stomach acid and bile that reflux into the esophagus from the stomach usually after eating
- Globus (sensation that there is a lump in the throat) :
-- Gastric refluxate into the larynx and pharynx resulting from GERD
- pH of gastric aspirate :
-- Acid refluxate from the stomach has a pH of 1.5 to 2.0, whereas the normal pH of the esophagus is 6.0 to 7.0

Actions :
Medication management :
- Antacids :
-- Neutralize or buffer stomach acid
- Histamine receptor agonists :
-- Acid production is decreased
- Proton pump inhibitors :
-- Acid production is blocked
- Prokinetic medications :
-- Gastric emptying is increased with prokinetic medications such as Regulan. Long-term use is not recommended because of the possibility of psychotropic or neurological side effects such as tardive dyskinesia
- Position the patient on the right side with the HOB elevated 6 to 12 inches :
-- Lying on the right side promotes gastric emptying, and elevating HOB promotes peristalsis and uses gravity to return gastric refluxate from the esophagus to the stomach. Sleeping in this position also decreases reflux at night
- Provide 4-6 meals per day :
-- Eating three larger meals per day increases pressure in the stomach and delays gastric emptying. Eating four to six smaller meals decreases pressure

Teaching :
- Educate the patient to limit the following foods and substances : spicy/fatty foods, caffeine, chocolate, carbonated beverages, acidic foods, peppermint, alcohol, and certain medications (if possible), such as calcium channel blockers, anticholinergic medications, and smooth muscle relaxers :
-- These foods, substances, and medications are associated with decreasing LES pressure, which allows gastric reflux from the stomach into the esophagus
- Avoid smoking and alcohol :
-- Both smoking and alcohol may lead to a decrease in LES pressure, increasing the risk of reflux
- Avoid NSAIDs and aspirin :
-- Both NSAIDs and aspirin can irritate the lining of the esophagus
- Encourage the patient to eat meals 2 hours before lying supine :
-- Eating large meals causes delayed gastric emptying and leads to gastric reflux
- Educate the patient to wear nonrestrictive clothing :
-- Tight clothing causes an increase in intra-abdominal pressure, which weakens the LES and contributes to GERD
- Educate the patient and family about maintaining ideal body weight :
-- Obesity increases intra-abdominal pressure, increasing the hiatal hernia and GERD
Hemorrhoids - Medical Management

- External hemorrhoids are diagnosed by :
-- Visual inspection
- Internal hemorrhoids are diagnosed by :
-- Digital examination
-- Anoscopy → procedure involving a small, tubular instrument inserted into the anal canal for inspection
-- Sigmoidoscopy
- Treatments is usually conservative and involves relief of symptoms & associated pain
-- Cold packs & sitz baths (warm water baths covering the hips and buttocks)
-- Three or four times a day to reduce some swelling and decrease pain
- If conservative therapy does not alleviate symptoms within 3 to 5 days, patient needs to referred to primary care provider
- Patient is encouraged to :
-- Consume adequate fluid and fiber
-- To decrease constipation associated with hemorrhoids
- Stool softeners may also be recommended
- Topical nitroglycerin (0.4%) ointment may be used to decrease pain caused by thrombosed hemorrhoids as well as topical nifedipine
- There are a number of OTC preparations available in creams and suppositories used to treat hemorrhoids

Medications Used for the Treatment of Hemorrhoids
• local anesthetics --> benzocaine, dibucaine, lidocaine --> provide temporary relief from burning, itching, and pain
• protectants/emollients --> cocoa butter, lanolin, white petroleum, zinc oxide, mineral oil, cod liver oil, or shark liver oil --> form physical barrier on the skin to prevent irritation of the perianal region
• astringents --> calamine, zinc oxide, witch hazel --> promote skin dryness, which helps relieve itching, irritation, and inflammation
• corticosteroids --> hydrocortisone --> reduce inflammation
Irritable Bowel Syndrome - Medical Management - Complementary & Alternative Therapies

- Diagnosis :
-- No diagnostic tests that show definitive diagnosis of IBD
-- However a number of tests may be performed to rule out other pathophysiological causes for concern
-- These test may include :
--- Flexible --- sigmoidoscopy
--- Colonoscopy
--- CT scan
--- Lactose intolerance tests
--- Stool cultures
--- Blood test
- After organic causes have been ruled out, - - Rome IV or Manning Criteria are used to make the diagnosis of IBS
Rome IV Diagnostic Criteria for Functional Gastrointestinal Disorders is one of the most common diagnostic instruments
- Patient must have had recurrent abdominal pain or discomfort at least 1 day per week in the last 3 months associated with two or more of the following :
-- Improvement with defecation
-- Onset associated with a change in frequency of stool
-- Onset associated with a change in form (appearance) of stool
- Manning Criteria → the more clinical manifestations the patient has, the greater likelihood of being diagnosed with IBS :
-- Pain relieved with defecation
-- More frequent stools at the onset of pain
-- Looser stools at the onset of pain
-- Visible abdominal distention
-- Passage of mucus
-- Sensation of incomplete evacuation
- Based on clinical presentation and results of these two tools, an individualized management plan is developed

Treatment
- Focus of medical treatment is on :
-- Controlling spasm
-- Minimizing diarrhea
-- Releasing neurotransmitters to promote peristalsis
-- Addressing depression
- Other treatments noted to be successful in the treatment of IBS :
-- Cognitive-behavioral therapy
-- Relaxation
-- Stress management
-- Acupuncture
-- Hypnosis
-- Chinese herbs
- Diet high in fiber may also help control symptoms associated with IBS because a bulkier stool reduces tension on the sigmoid colon

Dietary Modification :
- Encouraged to maintain a food diary & note any foods that trigger symptoms
- Diet low in fermentable oligo-, di-, and monosaccharides and polyols (FODMAPs) are noted to improve symptoms
- Short-chained carbs are poorly absorbed and cause some abdominal bloating
- Foods to avoid :
-- Fructose
-- Apples
-- Pears
-- Mangoes
-- Cherries
-- Wheat
- Patients eliminate FODMAPs from diet for 6 to 8 weeks
- After resolution of symptoms, they are gradually re-introduced to determine tolerance for specific foods
- Patients should also be encouraged to avoid gas-producing foods
- Some patients benefit from avoiding lactose as well
- Nonceliac gluten sensitivity (NCGS) has been thought to affect IBS-D patients but the evidence has been inconsistent

Complementary & Alternative Therapies :
- Relaxation techniques :
-- Acupuncture
-- Hypnosis
-- Hypnotherapy
- Probiotics often help symptoms in some patients
-- Some patients with IBS may not have enough "good bacteria" and taking probiotics may help ease clinical manifestations
-- Not completely understood, but there have been some general benefits including :
--- Suppressed growth or epithelial binding by pathogenic bacteria
--- Improved function of intestinal barriers
-- Effective ways of relieving stress and anxiety :
--- Regular exercise
--- Yoga
--- Massage
--- Meditation
-- Some Chinese herbs demonstrated some relief but use with caution & only under advice of HCP :
-- Peppermint (Mentha piperita) and fennel (Foeniculum) are natural antispasmodics and have anti-inflammatory properties. They relax smooth muscle in the intestines and help expel gas
-- Chamomile (Chamaemelum nobile) tea have gentle antispasmodic properties
--Ginger - helps control nausea and expel gas
Inflammatory Bowel Disease - Clinical Manifestations

- Chronic in nature & severity ranges from mild to severe, with periods of remission and exacerbations
- Exacerbations often precipitated by physical or emotional stress
- Similarities between Crohn's disease & ulcerative colitis :
-- Persistent diarrhea
-- Abdominal pain or cramps
-- Fever
-- Weight loss
-- Fluid imbalances
-- Malnutrition
-- Mouth ulcers
-- Anemia
-- Blood from rectum
-- Joint, skin, or eye irritations
-- Delayed growth
- Extraintestinal manifestations include :
-- Uveitis (intraocular inflammatory disorder)
-- Sclerosing cholangitis (inflammation of the hepatic ducts)
-- Nephrolithiasis (renal stones)
-- Cholelithiasis (gallstones)
-- Joint disorders
-- Skin disorders
-- Oral ulcerations
- Patients with Crohn's disease are at higher risk for cancer of small bowel, whereas patients with ulcerative colitis are at higher risks for colon cancer after having the disease for long period of time
- No medical cure for either disease :
-- Colectomy (removal of large intestine) cures ulcerative colitis in the GI tract
-- However having colectomy does not cure extraintestinal manifestations associated with ulcerative colitis
- Patients with crohn's disease who undergo surgical resection of diseased section of the bowel are at increased risk of recurrences at the site of the :
-- Anastomoses → area where the two sections of the bowel were reattached after removal of diseased bowel
- Patients with IBD usually present to HCP with :
-- Abdominal pain
-- Diarrhea
-- Fluid and/or electrolyte imbalances
-- Weight loss

Comparison of Crohn's Disease & Ulcerative Colitis
Crohn's Disease :
• Region/location affected --> terminal ileum (most common), sometimes colon with patchy involvement throughout all layers of the bowel, skip lesions; can occur anywhere in the GI tract from mouth to anus
• Distribution of lesions --> trasmural, all layers
• Characteristic stool --> loose, semiformed
• Number of stools per day --> 5-6 soft, loose nonbloody
• Granuloma --> common
• Fistula, fissure, abscess --> common
• stricture, obstruction --> common
• Malabsorption, malnutrition --> yes
• Etiology --> unknown
• Peak incidence age --> 15-35 years
• Complications --> fistulas, nutritional deficiencies
• Need for surgery --> frequent
• Fever (intermittent) --> common
• Weight loss --> common, may be severe
• Tenesmus --> rare
• Cobblestone appearance of mucosa --> common
• Pseudopolyps --> rare
• Small bowel involvement --> common
• Fistulas --> common
• Strictures --> common
• Anal abscess --> common
• Perforation --> common (transmural)
• Recurrence after surgery --> common at site of anastomosis

Ulcerative Colitis
• Region/location affected --> colon, rectum; begins in the rectum and proceeds in a continuous, diffuse pattern toward the cecum
• Distribution of lesions --> mucosa and submucosa only of the colon
• characteristic stool --> frequent, watery, with blood and mucus
• Number of stools per day --> 10-20 liquid, bloody
• Granuloma --> occasional
• Fistula, fissures, abscess --> rare
• Stricture, obstruction --> rare
• Malabsorption, malnutrition --> not common or minimal incidence
• Etiology --> unknown
• Peak incidence age --> 15-25 years and 55-65 years
• Complications --> hemorrhage, nutritional deficiencies
• Need for surgery --> infrequent; cure with colectomy
• Fever (intermittent) --> during acute attacks
• Weight loss --> rare
• Tenesmus --> common
• Cobblestone appearance of mucosa --> rare
• Pseudopolyps --> common
• Small bowel involvement --> minimal, only backwash into ileum
• Fistulas --> rare
• Strictures --> occasional
• Anal abscess --> rare
• Perforation --> common (toxic megacolon)
• Recurrence after surgery --> cure with colectomy
Celiac Disease - Nursing Interventions - Assessment & Actions

Assessments :
- Vital signs :
-- Due to diarrhea, there is an increased fluid loss that may lead to signs of hypovolemia, including decreased blood pressure, orthostatic hypotension, and tachycardia. Temperature maybe elevated due to the inflammatory process or fluid volume deficit
- Serum electrolytes :
-- There may be increased loss of potassium due to the diarrhea, and decreased absorption of calcium due to intestinal mucosal damage. With hypocalcemia, the patient may demonstrate Chvostek or Trousseau signs
- CBC :
-- Anemia may develop secondary to malabsorption of key nutrients, as well as potential intestinal bleeding due to mucosal wall destruction
- Intake and output :
-- Diarrhea develops secondary to damage to the surface of the intestinal wall. The diarrhea may be watery, frothy, light in color, with a foul odor
- DXA (Dual energy x-ray absorptiometry) :
-- The patient is at risk of osteopenia and osteoporosis secondary to malabsorption of calcium
- Current knowledge of the gluten-free diet :
-- Assessment of the patient's current knowledge needs to be established before beginning any teaching. Gluten may be in foods and products that the patient does not associate with this protein found in wheat, rye, and barley

Actions :
- Refer patient to a dietician knowledgeable in celiac disease for gluten-free diet teaching :
-- It is always important to involve other members of the healthcare team with more expertise in an area in order to enhance the patient's knowledge
- Refer to support group for celiac disease :
-- Support groups help the patient to learn more about the disease as well as coping strategies used by others
- Develop a trusting relationship :
-- A trusting relationship is necessary in all patient encounters and assists the patient in sharing important information with a non-judgemental approach
- Encourage patients to ask about gluten-free choices when dining out :
-- If gluten-free choices are not on the menu, the patient can help encourage the restaurant to include these choices in the future
Diverticulitis - Medical Management

Diagnosis :
- Most common diagnostic tests :
-- Plain flat-plate abdominal x-rays
-- But diagnosis is usually confirmed with a CT scan
-- CT scan also helps differentiate from other sources of abdominal pain and complicated cases of diverticulitis
- WBCs are monitored for elevations initially associated with inflammation and possible infection but should decrease with treatment
- Urinalysis may show → few RBCs if ureter is near a perforated diverticulum
- Patient with suspected diverticulitis should not have barium enema because of risk of rupturing the diverticula

Treatment :
- Uncomplicated diverticulitis :
-- Treated on outpatient basis
-- Broad-spectrum antibiotics for 7-10 days but should be reassessed after 2-3 days of therapy
-- Consume clear liquid diet until symptoms subside, then diet should be advanced slowly as tolerated
- Common antibiotics used to treat diverticulitis :
-- Ciprofloxacin & metronidazole
-- Trimethoprim-sulfamethoxazole & metronidazole
-- Amoxicillin-clavulanate
-- Augmentin or Moxifloxacin
- Patient should be admitted to hospital for
-- fever >102.5F (39C)
-- Microperforation (few air bubbles outside the colon or confined to the pelvis)
-- Immunosuppression
-- Significant leukocytosis
-- Severe abdominal pain or diffuse peritonitis
-- Advanced age
-- Significant comorbidities
-- Intolerance of oral intake
-- Noncompliance or failed outpatient treatment
- No dietary restrictions in acute uncomplicated diverticulitis, although limiting to a clear liquid diet for 2-3 days is common, while advancing as tolerated
- If patient is admitted to hospital :
-- IV fluids are started
-- NPO to allow bowel to rest
-- Patient may have NG tube for bowel decompression and will receive parenteral antibiotics
-- Laxatives and enemas should be avoided because they increase intestinal motility
-- Pain medications prn & opiates are frequently needed
-- Inpatients may be discharged as clinical manifestations resolve and should complete a course of 10-14 days of antibiotics and then have a follow up examination
-- After clinical manifestations completely resolve, patient is recommended to have a colonoscopy to assess the extent of the diverticular disease
Hepatitis - Pathophysiology

- Inflammation of liver cells mostly caused by a virus that impairs its ability to function normally
- This inflammation limits the ability of the liver to :
-- Detoxify substances
-- Limits the production of proteins and clotting factors
-- Alters the ability to store vitamins, fats, and sugars
- Modes of transmission of viral hepatitis include:
-- Contact with blood
-- Blood products
-- Semen
-- Saliva
-- Mucous membranes
-- Direct contact with infected fluids or objects
-- Fecal-oral route with contaminated water or food such as shellfish
- Patients with hepatitis may experience a mild or severe illness that can be acute or chronic
- Viruses of hepatitis are classified according to letters ranging from A to G, each of which differs in :
-- Its incubation period
-- Mode of transmission
-- & other characteristics
- Most common hepatitis viruses → A, B, and C
- Diagnosis of type is made by using a specific serological profile

Hepatitis A
• route of tranmission : fecal-oral, contaminated water or food
• source of virus : feces, contaminated water or food
• incubation period : 15-50 days
• acute or chronic : acute
• available vaccine : yes
• treatment : symptomatic

Hepatitis B
• route of transmission : percutaneous or mucosal blood, body fluids, needles or sharps instruments
• source of virus : blood, body fluids
• incubation period : 45-60 days
• acute or chronic : chronic
• available vaccine : yes
• treatment : interferon and antivirals

Hepatitis C
• route of transmission : percutaneous or mucosal blood, body fluids, needs or sharp instruments
• source of virus : blood, body fluids, needles or sharp instruments
• incubation period : 2-25 weeks
• acute or chronic : chronic
• available vaccine : no
• treatment : interferon and antivirals

Hepatitis D
• route of transmission : percutaneous or mucosal in conjunction with hepatitis B, blood, body fluids, or sharp instruments
• source of virus : blood, body fluids, needles or sharp instruments
• incubation period : 2-8 weeks
• acute or chronic : acute
• available vaccine : prevented with HBV vaccine
• treatment : interferon and antivirals
- Hepatic encephalopathy presents with :
-- Impaired mentation
-- Altered levels of consciousness
-- Confusion
-- Somnolence (drowsy)
-- Insomnia
-- Due to accumulation of toxins in bloodstream that are normally cleared by a healthy liver
- In severe hepatic failure, liver is unable to metabolize waste secondary to severe inflammation, and because the hepatocytes (liver cells) are not functioning properly
- Additionally, due to scarring of the liver :
-- Blood bypasses the liver and is not detoxified
- As a result :
-- Waste products accumulate, specifically ammonia
-- Causing changes in mental status
- Additional complications of liver failure include :
-- Inability of the liver to produce clotting factors
-- Resulting in coagulation disorders and thrombocytopenia (low blood platelet count)

Hepatitis E
route of transmission : fecal-oral, contaminated water or food
• sources of virus : feces
• incubation period : 2-8 weeks
• acute or chronic : acute
• available vaccine : no
• treatment : symptomatic

Hepatitis G
• route of transmission : infected blood or blood products
• source of virus : infected blood or blood products
• incubation period : unknown
• acute or chronic : acute
• available vaccine : no
• treatment : symptomatic

- Hepatic encephalopathy presents with :
-- Impaired mentation
-- Altered levels of consciousness
-- Confusion
-- Somnolence (drowsy)
-- Insomnia
-- Due to accumulation of toxins in bloodstream that are normally cleared by a healthy liver
- In severe hepatic failure, liver is unable to metabolize waste secondary to severe inflammation, and because the hepatocytes (liver cells) are not functioning properly
- Additionally, due to scarring of the liver :
-- Blood bypasses the liver and is not detoxified
- As a result :
-- Waste products accumulate, specifically ammonia
-- Causing changes in mental status
- Additional complications of liver failure include :
-- Inability of the liver to produce clotting factors
-- Resulting in coagulation disorders and thrombocytopenia (low blood platelet count)
Medical Management :
Diagnosis :

- AST
-- Extremely high level (usually 10 times the normal range) indicates acute hepatitis most often caused by a virus but can also be associated with exposure to meds or other hepatotoxins
-- Usually remain elevated for 1 to 2 months but can take as long as 3 to 6 months to return to normal
- ALT
- Serum albumin
-- Measures amount of protein that is made by the liver
-- Low levels → liver damage & malnutrition
-- Bilirubin is by-product of the breakdown of RBCs that is filtered through the liver
-- Two measurements of bilirubin :
--- Direct (conjugated)
---- Measures serum level of bilirubin in the liver while it binds to certain sugars
---- It is then released into the bile and stored in the gallbladder
--- Indirect (unconjugated)
---- Measures serum level of bilirubin before it gets to the liver
--- When liver is unable to conjugate the bilirubin because of dysfunction, levels are elevated, and patients develop jaundice
- Lactate dehydrogenase (LDH) → test for an enzyme produced by many organs in the blood as the result of tissue damage
-- Not used solely to help determine liver disease
-- Used in conjunction with those listed previously to determine the presence & severity of liver dysfunction
- Ratios of AST to ALT can help determine whether the liver disease is viral in origin or associated with a toxin or alcohol exposure
- Two lab values that indicate abnormalities of bile flow :
-- GGT (gamma glutamyl transferase)
--- Protein found in liver & bile ducts
--- High levels can indicate :
---- Inflammation
---- Injury
---- Blockage of the bile ducts (cholestasis)
--- Alkaline phosphatase
---- Found in the bone, intestines, liver, and bile ducts
---- Elevated indicates :
----- Blockage of bile flow that can be caused by gallstones or scarring in the biliary tree

Diagnostic Testing for Liver Disorders
• ALT :
male : 13-40 units/L
female : 24-36 units/L
• AST :
male : 20-40 units/L
female : 15-35 units/L
• Alkaline phosphatase (total) :
male : 35-142 units/L
female : 25-125 units/L
• Alkaline phosphatase (liver function) :
0-93 units/L
• GGT :
male : 0-30 units/L
female : 0-24 units/L
• LDH :
90-176 units/L
• Bilirubin, total :
0.3-1 mg/dL
• Bilirubin, indirect :
0.2-0.8 mg/dL
• Bilirubin, direct :
0.1-0.3 mg/dL
• Albumin :
3.4-5.1 g/dL
• Ammonia :
15-60 mcg/dL
• Coagulation tests -
• PT : 10-13 seconds
• PTT : 25-35 seconds
• Platelets : 150,000-450,000 mm3



Medications :
- Oral antiviral agents for viral suppression
- Pegylated interferon injections also work toward viral suppression
- Hepatitis A vaccine recommended :
-- Immune globulin if exposure to source of hepatitis A was <2 weeks
- Hepatitis B vaccine recommended :
-- All children & adults in high-risk categories
- Most oral agents used to treat hepatitis B are given daily for as long as 1 year or longer to slow or stop the growth of the virus
- Injections of the interferons can be weekly or multiple times a week for 6 to 12 months
- Patients undergoing medical treatment are followed serially over time to monitor liver function tests (LFTs) and treatment response
Hepatitis - Nursing Interventions - Teaching

Nursing Interventions :
Assessments :
- Vital signs :
-- Elevation in temperature and pulse associated with infectious process
- Serum liver enzymes :
-- Elevated levels of liver enzymes indicate that liver injury is present and liver enzymes have entered the bloodstream
- Serum bilirubin :
-- Bilirubin is a by-product of RBC breakdown, and liver is responsible for removing bilirubin in the blood. Total bilirubin and direct, or conjugated, bilirubin levels are elevated because of inflammation and obstruction of the liver by hepatitis
- Color of skin, sclera :
-- Yellow pigmentation of the eyes and skin occurs because of increased levels of bilirubin in the blood. Deep jaundice may result in a greenish tint to the skin due to by-products of bilirubin conversion
- Nutritional intake :
-- Loss of appetite occurs because of abdominal fullness or lack of desire to eat foods the patient previously enjoyed as a result of indigestion. This occurs frequently with fatty foods and alcohol
- Daily weight :
-- Monitors nutritional intake and evaluates weight loss associated with decreased nutritional intake. Anorexia may develop secondary to abdominal distention and obstruction. An increase in body weight may be secondary to ascites
Intake and output :
Fluid volume status, either overload or depletion, may occur. Fluid overload is often associated with ascites that develops secondary to damage to liver by the inflammatory and infectious processes seen with hepatitis
- Signs of organ rejection in the patient after liver transplantation :
-- In patients who undergo transplantation for cirrhosis, organ rejection may occur within the first 10 days after the procedure and may include RUQ pain, changes in bile drainage, ever, tachycardia, and jaundice

Actions :
- Administer meds as ordered :
-- Administer meds as ordered for management of specific hepatitis type if indicated
- Provide small, frequent meals and supplements (as needed)
-- Because of decrease appetite and feelings of fullness, small, frequent meals and nutritional supplements are encouraged to promote adequate nutrition
- Administer antiemetics :
-- Antiemetics decrease symptoms of nausea and vomiting associated with the virus, which may occur for a prolonged time. Use caution; some antiemetics (phenothiazines) are metabolized by the liver and should not be used
- Promote balance between physical activity and rest :
-- Rest decreases metabolic demands on the liver
- Encourage rest periods between walking and physical activity :
-- Maintains strength and conditions

Teaching :
- Nutritional teaching :
-- Importance of balanced nutrition to promote energy and small, frequent meals to increase nutritional intake while minimizing the negative effects of eating.
-- Patients with clinical manifestations of hepatitis such as nausea and vomiting tend to limit food intake.
-- It is important to stress calorie intake and proteins in moderate doses because the liver processes protein
vitamins and minerals with a balanced diet or supplements
-- Limit fat intake because liver may not be able to make enough bile to process fats
-- Small frequent meals indicated because liver cannot store glycogen for energy because of inflammation
-- Hydration is important to manage symptoms including :
-- Dizziness
-- Fatigue
-- Skin and mucous membrane dryness
-- Side effects of of any meds
- Alcohol & caffeine should be avoided as they may cause dehydration
- Good hand hygiene before and after meals and use of the bathroom to decrease transmission from fecal-oral route :
-- Practice good hand hygiene before and after eating and after using the toilet to decrease transmission from the fecal-oral route
- Avoid behaviors (needle sharing, unprotected sex) that contribute to transmission :
-- Avoiding behaviors that expose patients to the virus decreases transmission. Mode of transmission of the diagnosed form of hepatitis must be included in the discharge teaching
- Importance of vaccines to prevent hepatitis A and hepatitis B :
-- Hepatitis A vaccine can prevent hepatitis A. Recommended for :
--- Healthcare workers
--- Food handlers
--- Childcare workers
--- Travelers to endemic hepatitis A areas
-- Series of two injections (initial injection and booster 6-12 months later)
-- Effective for as long as 20 years
-- Hepatitis B vaccine can prevent hepatitis B and the serious consequences of HBV infection including :
--- Liver cancer
--- Cirrhosis
-- Usually given as a series of several injections
-- Gives long-term protection from HBV infection.
-- Recommended for everyone
- Safe public water supply, sewage :
--- Consider the water source and whether the public water supply is safe from sewage. Infected fecal matter can transmit hepatitis A
Cirrhosis - Medical Management - Diagnosis - Safety

Medical Management :
Diagnosis :
- CT scans :
-- Noninvasive tests to determine abnormalities of the liver
- EGD :
-- Minimally invasive procedure that uses an endoscope to visualize the GI tract from the esophagus to the duodenum to evaluate for esophageal varices or bleeding
- Percutaneous transhepatic portal angiography :
-- Visualize the portal venous system and liver biopsy. ERCP is a technique that combines endoscopy and fluoroscopy to visualize the biliary system to diagnose and treat causes of obstruction in the biliary tree
- Percutaneous transhepatic cholangiography :
-- Radiological test that uses a contrast medium injected into the bile duct of the liver to visualize the biliary tract and identify obstruction that if identified, can be treated with the insertion of drains or stents
- Liver biopsy :
-- Noninvasive procedure done to collect a sample of liver tissue to determine the severity of liver disease
-- Can be done percutaneously, transvenously, or directly in the operating room through the abdomen. Patients who undergo liver biopsy are usually maintained on bedrest for several hours post procedure, sometimes with a 5- to 10-lb sandbag over the biopsy site. Careful monitoring is required after the procedure associated with the risk of hypotension and bleeding

Safety :
- A change in the patient's level of consciousness or a decrease in blood pressure and increase in heart rate after a liver biopsy may indicate severe bleeding associated with the procedure, and the nurse should immediately notify the HCP

Cirrhosis - Medical Management :
Treatment :
- Ascites requires restriction of sodium intake to <2 g per day & administration of diuretics to increase salt and water excretion
- Patients receive combo of diuretics such as :
-- Spironolactone & furosemide
- Patients with end-stage liver disease, often secondary to cirrhosis :
-- Perform routine & frequent paracentesis for ascites that requires removal of several liters of fluid to relieve patient's clinical manifestations of abdominal bloating, pain, and SOB
-- With removal of fluid, patient may develop hypotension requiring close monitoring
- Treatment of portal hypertension involves :
-- Symptom management
-- Controlling complications of bleeding
-- Patients may undergo endoscopic procedures such as banding or sclerotherapy (procedure used to shrink veins)
--- Banding involves placing bands around the varices to block bleeding
--- Sclerotherapy involves the injection of a solution into the bleeding varices to make them shrink to stop bleeding
-- Some patients may also be given beta blockers to lower systemic blood pressure
- Historically, patients with uncontrolled esophageal variceal bleeding were treated with :
Sengstaken-Blakemore tube
-- Inserted into GI tract through the nose to provide compression and traction in the esophagus and stomach to stop hemorrhage
-- This is rarely used
- Management of patients with hepatic encephalopathy (toxins from liver disease travels to brain, affecting brain function) includes :
-- Avoiding protein overload
--- Eat small, frequent meals
-- Decreasing bacterial production of ammonia
--- Patients usually receive neomycin & lactulose
--- Neomycin → broad spectrum antibiotic that destroys bacteria normally present in GI tract, decreasing protein breakdown and production of ammonia
--- Lactulose → promotes accretion of ammonia in stool and can be given orally or via rectal enemas
-- Correcting fluid and electrolyte imbalances
--- These treatments can cause diarrhea & altered fluid and electrolytes
--- So monitor fluid volume status & electrolyte values
--- Patients also receive vitamins A, B-complex, C, and K, as well as folic acid to correct abnormalities
Cirrhosis - Nursing Interventions - Assessment

Nursing Interventions :
Assessments :
- Respiratory status, SOB :
-- Adventitious breath sounds, decreased breath sounds, and increased respiration rate may indicate pulmonary fluid overload or inability to lower the diaphragm because of ascites
- Vital signs :
-- Blood pressure may be elevated because of fluid volume excess, but blood pressure may be low because of fluid shift out of the vascular space secondary to decreased oncotic pressure due to low serum albumin
- Peripheral edema secondary to fluid retention :
-- Fluid shift into tissues associated with retention of sodium and water, decreased albumin
- Abdominal girth :
-- Increased girth due to accumulation of fluid (ascites) in the peritoneal cavity secondary to fluid shifts caused by loss of intravascular plasma proteins
- Bleeding gums, ecchymosis (bruising), epistaxis (nosebleed), and petechiae (small, round spots on the skin as a result of bleeding) :
-- Complications of decreased clotting factors and vitamin K deficiency
- Skin, sclera, urine, and stool color :
-- Signs of jaundice (yellowish skin and sclera) along with dark urine and clay-colored stools are associated with increased bilirubin levels due to the inability of the liver to produce bile or because bile flow is blocked
- Mental status :
-- Signs of anxiety, behavioral or personality changes, lethargy, stupor, asterixis indicate hepatic encephalopathy secondary to elevated ammonia levels
- Intake and output :
-- Fluid status requires vigilant monitoring due to risk of fluid retention secondary to ascites, diarrhea, and potential blood loss
- Daily weight :
-- Increased weight indicated fluid retention
- Acid-base disorders :
-- Elevated serum ammonia levels, hyperventilation, and hypoxemia contribute to respiratory alkalosis. Metabolic alkalosis can occur because of vomiting and fluid loss, diarrhea, and the use of diuretics
- Signs of organ rejection :
-- In patients who undergo transplantation for cirrhosis, organ rejection may occur within the first 10 days after the procedure and may include RUQ pain, changes in bile drainage, fever, tachycardia, and jaundice

Actions :
- Administer diuretics :
-- Diuretics help decrease fluid overload and edema
- Administer electrolyte replacements such as potassium :
-- Maintain electrolytes within normal range. Potassium levels may be low associated with vomiting, diarrhea secondary to treatment for elevated ammonia levels, the use of diuretics, or low dietary intake of potassium-rich foods
- Administer magnesium as needed :
-- Hypomagnesemia in patients with a history of alcohol abuse is a result of poor nutrition and diarrhea
- Administer phosphate as needed :
-- Hypophosphatemia, or low phosphate levels, due to alcohol abuse, poor nutrition, use of diuretics
- Restrict sodium and fluid intake as ordered :
-- Prevents fluid accumulation and edema
- Restrict protein intake :
-- Elevated amounts of protein in the diet can raise ammonia levels and lead to hepatic encephalopathy
- HOB elevation and leg elevation :
-- Helps respiratory status by decreasing pressure on the diaphragm secondary to ascites and minimizes dependent edema
- Administer vitamin K, blood products, and fresh frozen plasma as ordered :
-- Corrects coagulation disorders secondary to liver's inability to synthesize clotting factors
- Promote rest periods between activities; sit down while bathing, dressing :
-- Decreases metabolic demand on liver, decreases oxygen demand, and prevents fatigue

Teaching :
- Overview of disease process and dietary restrictions (protein, sodium, fluid) :
-- Promotes knowledge of signs and symptoms of disease and promotes understanding of the importance of following dietary guidelines to prevent progression of the disease process
- Lifestyle changes :
-- No alcohol intake :
--- If alcohol is the cause of cirrhosis, remove alcohol from diet and refer to support groups
-- Educate about medications that are metabolized in the liver as acetaminophen (tylenol) and OTC herbs and supplements :
--- These meds can cause further liver damage
- Seek routine care for liver disease :
-- Encourage patient to be proactive in disease process and to monitor lab values and progression of disease
- Consume adequate calories to minimize weight loss, eating a well-balanced diet with plenty of fruits, vegetables, and whole grains
-- Helps prevent malnutrition and provides body with adequate energy
- Need for care with hygiene, soft toothbrushes, careful flossing, electric razors :
-- Minimize risk of bleeding