2Laboratory and Diagnostic Examinations Serum bilirubin testLiver enzyme testsSerum protein testOral cholecystography (gallbladder series)Intravenous cholangiography (IV cholangiogram)Operative cholangiographyT-tube cholangiogramUltrasound of the liver, gallbladder, and biliary systemGallbladder scanningLiver biopsyLiver scanningWhen the body becomes jaundiced, a yellow skin discoloration results. When visualization of jaundice results, the total serum bilirubin exceeds 2.5 mg/dL.What types of information can be gleaned from the bilirubin values?The results provide information for diagnosis and evaluation of liver disease, biliary obstruction, erythroblastosis fetalis, and hemolytic anemia.What is the rationale for assessing liver enzymes? Why do their levels change with liver disease?Injury and diseases promote the release of intracellular enzymes into the bloodstream.
3Laboratory and Diagnostic Examinations (continued)Blood ammoniaHepatitis virus studiesSerum amylase testUrine amylase testUltrasound of pancreasComputerized tomography of the abdomenEndoscopic retrograde cholangiopancreatography of the pancreatic duct (ERCP)What nursing assessments must be performed before each of the listed diagnostic tests?
4Disorders of the Liver, Biliary Tract, Gallbladder, and Pancreas CirrhosisEtiology/pathophysiologyChronic, degenerative disease of the liverScar tissue restricts the flow of blood to the liverTypes of cirrhosisLaennec’s cirrhosisPostnecrotic cirrhosisPrimary biliary cirrhosisSecondary biliary cirrhosisCirrhosis is the fourth leading cause of death in the United States for adults between 40 and 60.During its progression, cirrhosis causes the degeneration of liver tissue, which results in the formation of fibrous tissue and fat infiltration of the lobules. These events cause the reduction of blood flow, further compounding the problem.There are different types of cirrhosis. Discuss the different types of cirrhosis and their causes.
5Disorders of the Liver, Biliary Tract, Gallbladder, and Pancreas Cirrhosis (continued)Etiology/pathophysiology (continued)Alteration of liver functionReduced ability to metabolize albuminObstruction of portal veinIncreased pressure in veins that drain GI tractComplicationsPortal hypertensionAscitesEsophageal varicesHepatic encephalopathyAs cirrhosis continues to progress, there are resulting complications. These complications include portal hypertension, ascites, esophageal varices, and hepatic encephalopathy. What is the underlying cause of each of these?
6Disorders of the Liver, Biliary Tract, Gallbladder, and Pancreas Cirrhosis (continued)Clinical manifestations/assessmentEarly stagesAbdominal painLiver is firm and easy to palpateLate stagesDyspepsiaChanges in bowel habitsNausea and vomitingGradual weight lossWhen providing care to a patient diagnosed with cirrhosis, what nursing interventions are appropriate?
7Disorders of the Liver, Biliary Tract, Gallbladder, and Pancreas Cirrhosis (continued)Clinical manifestations/assessment (continued)Late stages (continued)AscitesEnlarged spleenSpider angiomasAnemiaBleeding tendenciesEpistaxisAs cirrhosis continues the physiological destruction of the liver, there is an increase in the severity of clinical manifestations. What factors should be assessed for the patient?
8Disorders of the Liver, Biliary Tract, Gallbladder, and Pancreas Cirrhosis (continued)Clinical manifestations/assessment (continued)Late stages (continued)PurpuraHematuriaBleeding gumsJaundiceDisorientationWhat teaching should be provided to the patient concerning cirrhosis?
9Systemic clinical manifestations of liver cirrhosis. Figure 6-2(From Lewis, S.M., Heitkemper, M.M., Dirksen, S.R. . Medical-surgical nursing: assessment and management of clinical problems. [7th ed.]. St. Louis: Mosby.)Systemic clinical manifestations of liver cirrhosis.
10Disorders of the Liver, Biliary Tract, Gallbladder, and Pancreas Cirrhosis (continued)Medical management/nursing interventionsPharmacological managementAntiemeticsBenadryl and DramamineContraindicated: Vistaril, Compazine, and AtaraxEliminate the causeAlcoholHepatotoxinsEnvironmental exposure to harmful chemicalsThe removal of the underlying causes of liver damage can aid in the prevention of additional damage to the structure.What is a commonly taken over-the-counter hepatotoxin?Antiemetics can be administered to reduce nausea and vomiting. What nursing assessments and diagnostic monitoring must accompany the administration of these medications?
11Disorders of the Liver, Biliary Tract, Gallbladder, and Pancreas Cirrhosis (continued)Medical management/nursing interventions (continued)DietWell-balancedHigh in caloriesModerate in proteinLow in fatLow in sodiumSupplemental vitamins and folic acidDiet management is vital in the treatment of cirrhosis. Ideally the diet should include between 2,500 and 3,000 calories per day.What are the goals of dietary modifications?Diet therapy is aimed at correcting malnutrition and promoting regeneration of the functional liver tissue and compensating for the liver’s deficits.What are the caloric needs of the patient diagnosed with cirrhosis?
12Disorders of the Liver, Biliary Tract, Gallbladder, and Pancreas Cirrhosis (continued)Medical management/nursing interventions (continued)Treatment of complicationsAscitesBed restStrict I&ORestrict fluids and sodiumDiuretics: Aldactone, Lasix, HCTZVitamins K, C, and folic acid supplementsLeVeen peritoneal-jugular shuntParacentesisThe severity of ascites will determine the medical management employed.At the very least, intake and output will be monitored.Diuretics can be prescribed. Review the mode of action for diuretics.If the ascites is severe, a paracentesis can be done. What nursing care should be performed before and after the procedure?
13LeVeen continuous peritoneal jugular shunt. Figure 6-3The LeVeen shunt allows for continuous shunting of ascitic fluid from the abdominal cavity via a one-way, pressure-sensitive valve into a silicone tube and empties into the superior vena cava.What complications are associated with the use of the LeVeen shunt?Congestive heart failure, leakage of ascitic fluid, infection at the insertion site, peritonitis, septicemia, and shunt thrombosis.(From Beare, P.G., Myers, J.L. . Adult health nursing. [3rd ed.]. St. Louis: Mosby.)LeVeen continuous peritoneal jugular shunt.
14Disorders of the Liver, Biliary Tract, Gallbladder, and Pancreas Cirrhosis (continued)Medical management/nursing interventions (continued)Treatment of complications (continued)Ruptured esophageal varicesMaintain airway; establish IVVasopressin drip to control bleedingSengstaken-Blakemore tubeEndoscopic sclerotherapyPortacaval shuntBlood transfusionEsophageal varices occur because of portal hypertension. What is the primary goal of esophageal varices management?The avoidance of further bleeding and hemorrhage.What actions can result in bleeding or hemorrhage of the varices?
15Disorders of the Liver, Biliary Tract, Gallbladder, and Pancreas Cirrhosis (continued)Medical management/nursing interventions (continued)Treatment of complications (continued)Hepatic encephalopathyDecrease protein in dietAvoid drugs that are detoxified by the liverLactuloseNeomycinHepatic encephalopathy is a type of brain damage caused by ammonia intoxication.What clinical manifestations can accompany this complication?In an effort to restrict protein and reduce ammonia formation in the intestines, dietary management might be needed. What foods would be appropriate for the diet of a patient experiencing hepatic encephalopathy? What foods should be avoided?
16Disorders of the Liver, Biliary Tract, Gallbladder, and Pancreas Liver cancerEtiology and pathologyHepatocellular carcinoma most commonly seenCirrhosis of the liver and hepatitis C and B are also elevated risk factorsIn the United States liver cancer is seen more in people over age 40Metastatic carcinoma of the liver is seen more than primary liver cancerIncreases in liver cancer in the United States are tied to an increased incidence of hepatitis C.
17Disorders of the Liver, Biliary Tract, Gallbladder, and Pancreas Liver cancerClinical manifestationsHepatomegalyWeight lossPeripheral edemaAscitesPortal hypertensionDull epigastric painJaundiceAnorexia
18Disorders of the Liver, Biliary Tract, Gallbladder, and Pancreas Liver cancerDiagnostic testsLiver scanUltrasoundCT scanMagnetic resonance imagingERCPLiver biopsyDiagnosing liver cancer can be difficult.
19Disorders of the Liver, Biliary Tract, Gallbladder, and Pancreas Liver cancerMedical management/nursing interventionsPalliative careSurgeryChemotherapyThe prognosis for cancer of the liver is poor. What is the typical life expectancy for the patient with liver cancer?What nursing diagnoses would be appropriate for the patient diagnosed with liver cancer?
20Disorders of the Liver, Biliary Tract, Gallbladder, and Pancreas HepatitisEtiology/pathophysiologyInflammation of the liver resulting from several types of viral agents or exposure to toxic substancesHepatitis AMost commonOral-fecal transmissionHepatitis A is the most common type of hepatitis. It is estimated that up to 50% of people in the United States are infected by the time they reach adulthood.What reporting is required of patients diagnosed with viral hepatitis?Identify situations in which a person could become infected with hepatitis A.List interventions to aid in the prevention of hepatitis A.
21Disorders of the Liver, Biliary Tract, Gallbladder, and Pancreas Hepatitis (continued)Etiology/pathophysiology (continued)Hepatitis BTransmission by contaminated serum; blood transfusion, contaminated needles, dialysis, or direct contact with infected body fluidsHepatitis CTransmitted through contaminated needles and blood transfusionsHepatitis B was formerly known as serum hepatitis.Hepatitis B is associated with a long incubation period.
22Disorders of the Liver, Biliary Tract, Gallbladder, and Pancreas Hepatitis (continued)Etiology/pathophysiology (continued)Hepatitis DCo-infection with hepatitis BHepatitis EFecal contamination of waterRare in the United States; usually in developing countriesHepatitis D is also known as delta virus. It causes hepatitis as a co-infection with hepatitis B. It can progress to cirrhosis and chronic hepatitis.Hepatitis E is also referred to as enteric non-A non-B hepatitis.
23Disorders of the Liver, Biliary Tract, Gallbladder, and Pancreas Hepatitis (continued)Clinical manifestations/assessmentGeneral malaiseAching musclesPhotophobiaHeadachesChillsAbdominal painDyspepsiaNauseaProvide a brief summation of the differences in the incubation periods for the types of hepatitis.The signs and symptoms of viral hepatitis vary greatly among patients.
24Disorders of the Liver, Biliary Tract, Gallbladder, and Pancreas Hepatitis (continued)Clinical manifestations/assessment (continued)Diarrhea/constipationPruritusHepatomegalyEnlarged lymph nodesWeight lossJaundiceDark amber urineClay-colored stoolsTwo common clinical manifestations associated with hepatitis are pruritus and jaundice. What is the underlying cause of each of these symptoms?
25Figure 6-5 Severe jaundice. Review the key locations to assess the patient for jaundice.(From Kamal, A., Brockelhurst, J.C. . Color atlas of geriatric medicine. [3rd ed.]. St. Louis: Mosby-Year Book—Europe.)Severe jaundice.
26Disorders of the Liver, Biliary Tract, Gallbladder, and Pancreas Hepatitis (continued)Medical management/nursing interventionsTreat symptomsSmall, frequent mealsLow-fat, high-carbohydrateIV fluids for dehydrationVitamin C, vitamin B–complex, vitamin KAvoid unnecessary medications, especially sedativesManagement of the patient diagnosed with hepatitis is directed toward supportive therapy for the signs and symptoms and prevention of disease spread to others.Dietary management includes vitamin B, vitamin B–complex, and vitamin K. What is the rationale for these supplements for the patient with hepatitis?
27Disorders of the Liver, Biliary Tract, Gallbladder, and Pancreas Hepatitis (continued)Medical management/nursing interventions (continued)Gamma globulin or immune serum globulinHepatitis B immune globulin (HBIG)Should be given to anyone exposed to hepatitis BHepatitis B vaccineShould be given to people identified as high risk for developing hepatitis BGamma globulin or immune serum globulin is a treatment geared toward patients who have been exposed to hepatitis B. When and how should these therapies be administered?Discuss the administration of the hepatitis B vaccine. Who are appropriate candidates for this medication?What is the prognosis for the patient who has been diagnosed with hepatitis?
28Disorders of the Liver, Biliary Tract, Gallbladder, and Pancreas Liver abscessesEtiology/pathophysiologyMay be single or multipleAbscess forms in the liver due to invading bacteriaLiver abscesses can form if a bacterial infection can become colonized. What are potential sources of this infection?
29Disorders of the Liver, Biliary Tract, Gallbladder, and Pancreas Liver abscesses (continued)Clinical manifestations/assessmentFeverChillsAbdominal pain and tenderness in the right upper quadrantHepatomegalyJaundiceAnemiaPatients having liver abscesses present with vague signs and symptoms. The most common complaints include fever, pain, and upper right quadrant tenderness.What nursing diagnoses would be appropriate for this patient?
30Disorders of the Liver, Biliary Tract, Gallbladder, and Pancreas Liver abscesses (continued)Diagnostic testsRadiographUltrasoundCT scanLiver scanMedical management/nursing interventionsIV antibiotic therapyPercutaneous drainage of liver abscessOpen surgical drainageThe prognosis for the patient with liver abscesses has improved over the past several years. What can be attributed to the improvements in clinical outcomes?
31Disorders of the Liver, Biliary Tract, Gallbladder, and Pancreas Cholecystitis and cholelithiasisEtiology/pathophysiologyAn obstruction, gallstone, or tumor prevents bile from leaving the gallbladder, and the trapped bile acts as an irritant, causing inflammationRisk factorsFemale; American Indian or white; obesity; pregnancy; diabetes; multiparous women; use of birth controlIn the United States, more than 500,000 patients are hospitalized with biliary system disorders.
32Common sites of gallstones. Figure 6-6What are potential complications associated with this condition?(from Monahan, F.D., et al. . Phipps’ medical-surgical nursing: health and illness perspectives. [8th ed.]. St. Louis: Mosby.)Common sites of gallstones.
33Disorders of the Liver, Biliary Tract, Gallbladder, and Pancreas Cholecystitis and cholelithiasis (continued)Clinical manifestations/assessmentIndigestion after eating foods high in fatSevere, colicky pain in the right upper quadrantAnorexiaNausea and vomitingFlatulenceIncreased heart and respiratory ratesDiaphoresisThe onset of symptoms might be sudden or demonstrated in a chronic manner with recurrent episodes of milder attacks.The clinical manifestations can cause the patient to believe he or she is experiencing a heart attack.Chronic attacks can be associated with the ingestion of a high-fat meal. Why does an elevated fat intake act as a catalyst for the attack?
34Disorders of the Liver, Biliary Tract, Gallbladder, and Pancreas Cholecystitis and cholelithiasis (continued)Clinical manifestations/assessment (continued)Low-grade feverElevated WBCMild jaundiceSteatorrhea (fatty stool)Dark amber urineObjective data collected might reflect an elevated leukocyte count, clay-colored stools, and amber-colored urine. Review the pathology responsible for these findings.
35Disorders of the Liver, Biliary Tract, Gallbladder, and Pancreas Cholecystitis and cholelithiasis (continued)Medical management/nursing interventionsMild attacksPharmacological managementAntispasmodic and analgesic medicationsAntibioticsBed restNG tube to suctionNPOIV fluidsDietary recommendations: Avoid spicy foods when allowed PO intakeManagement for mild attacks is typically conservative in nature.Conservative management seeks to rest the GI tract and the gallbladder.Pharmacological management includes antispasmodics, analgesics, and antibiotics.What is the rationale for each of the drug types prescribed?Review the rationale for the avoidance of morphine administration for patients experiencing biliary pain.
36Disorders of the Liver, Biliary Tract, Gallbladder, and Pancreas Cholecystitis and cholelithiasis (continued)Medical management/nursing interventions (continued)LithotripsyCholecystectomyLaparoscopicOpenLithotripsy and surgical management seek to break up or remove offending stones.What pre-procedure/preoperative patient education is needed for these patients?What are the nursing responsibilities for the postprocedure care of these patients?
37Disorders of the Liver, Biliary Tract, Gallbladder, and Pancreas PancreatitisEtiology/pathophysiologyInflammation of the pancreasAcute or chronicPredisposing factorsAlcoholTraumaInfectious diseaseCertain drugsPancreatitis is in inflammation of the pancreas. It can be acute or chronic. Discuss the pathophysiologic processes of this disorder.
38Disorders of the Liver, Biliary Tract, Gallbladder, and Pancreas Pancreatitis (continued)Clinical manifestations/assessmentAbdominal painAnorexia; nausea and vomitingMalaiseLow-grade feverJaundiceWeight lossSteatorrheaTachycardiaPatients having pancreatitis might express symptoms along a vast continuum. The most common is abdominal pain that radiates to the back. What is the root cause of the pain?What diagnostic tests can be used to support a diagnosis of pancreatitis?
39Disorders of the Liver, Biliary Tract, Gallbladder, and Pancreas Pancreatitis (continued)Medical management/nursing interventionsPharmacological managementAntiemeticsAnalgesicsAnticholinergicsAntacidsNPOIV fluidsNG tubeHyperalimentationUnless the cause of pancreatitis is related to biliary tract disease, the management of the disease is medical.Foods and fluid are restricted. What is the rationale for this intervention?Parenteral anticholinergics may also be indicated. What is the rationale for the administration of this classification of medication?Dietary management for chronic pancreatitis might be initiated. What would characteristics of this diet be?
40Disorders of the Liver, Biliary Tract, Gallbladder, and Pancreas Cancer of the pancreasEtiology/pathophysiologyUnknownRisk factorsCigarette smoking; exposure to chemical carcinogens; diabetes mellitus; pancreatitis; diet high in meat, fat, and coffeeMay be metastasis from the lung, stomach, duodenum, or common bile duct (CBD)May live only 4 to 8 months after diagnosisPancreatic cancer is the fourth leading cause of cancer death in the United States and Canada.To what can the high death rate be attributed?
41Disorders of the Liver, Biliary Tract, Gallbladder, and Pancreas Cancer of the pancreas (continued)Clinical manifestations/assessmentAnorexiaFatigueNausea and flatulenceChange in stoolsSteady, dull, aching pain in the epigastric areaWeight lossJaundiceOnset of diabetes mellitusIn addition to the assessment of physical signs and symptoms, the patient’s occupation should be investigated. What occupations would place a worker at higher risk of pancreatic cancer?
42Disorders of the Liver, Biliary Tract, Gallbladder, and Pancreas Cancer of the pancreas (continued)Medical management/nursing interventionsSurgeryWhipple procedureTotal pancreatectomy with resection of parts of the GI tractChemotherapyRadiationReview the diagnostic tests used to identify pancreatic cancer.What prognosis is associated with pancreatic cancer?
43Whipple’s procedure, or radical pancreaticoduodenectomy. Figure 6-9(From Lewis, S.M., Heitkemper, M.M., Dirksen, S.R. . Medical-surgical nursing: assessment and management of clinical problems. [7th ed.]. St. Louis: Mosby.)Whipple’s procedure, or radical pancreaticoduodenectomy.
44Nursing Process Nursing diagnoses Activity intolerance Noncompliance Breathing pattern, ineffectiveFluid volume, deficientHome maintenance, impairedInjury, risk forKnowledge, deficientNoncomplianceNutrition, imbalanced, less than body requirementsPain, acute/chronicPowerlessnessSkin integrity, impairedThought processes, disturbed