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Chapter 6 Care of the Patient with a Gallbladder, Liver, Biliary Tract, or Exocrine Pancreatic Disorder Mosby items and derived items © 2011, 2007 by Mosby,

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Presentation on theme: "Chapter 6 Care of the Patient with a Gallbladder, Liver, Biliary Tract, or Exocrine Pancreatic Disorder Mosby items and derived items © 2011, 2007 by Mosby,"— Presentation transcript:

1 Chapter 6 Care of the Patient with a Gallbladder, Liver, Biliary Tract, or Exocrine Pancreatic Disorder Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

2 Slide 2 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Laboratory and Diagnostic Examinations Serum bilirubin test Liver enzyme tests Serum protein test Oral cholecystography (gallbladder series) Intravenous cholangiography (IV cholangiogram) Operative cholangiography T-tube cholangiogram Ultrasound of the liver, gallbladder, and biliary system Gallbladder scanning Liver biopsy Liver scanning

3 Slide 3 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Laboratory and Diagnostic Examinations (continued) Blood ammonia Hepatitis virus studies Serum amylase test Urine amylase test Ultrasound of pancreas Computerized tomography of the abdomen Endoscopic retrograde cholangiopancreatography of the pancreatic duct (ERCP)

4 Slide 4 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Disorders of the Liver, Biliary Tract, Gallbladder, and Pancreas Cirrhosis  Etiology/pathophysiology Chronic, degenerative disease of the liver Scar tissue restricts the flow of blood to the liver Types of cirrhosis  Laennec’s cirrhosis  Postnecrotic cirrhosis  Primary biliary cirrhosis  Secondary biliary cirrhosis

5 Slide 5 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Disorders of the Liver, Biliary Tract, Gallbladder, and Pancreas Cirrhosis (continued)  Etiology/pathophysiology (continued) Alteration of liver function  Reduced ability to metabolize albumin  Obstruction of portal vein  Increased pressure in veins that drain GI tract Complications  Portal hypertension  Ascites  Esophageal varices  Hepatic encephalopathy

6 Slide 6 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Disorders of the Liver, Biliary Tract, Gallbladder, and Pancreas Cirrhosis (continued)  Clinical manifestations/assessment Early stages  Abdominal pain  Liver is firm and easy to palpate Late stages  Dyspepsia  Changes in bowel habits  Nausea and vomiting  Gradual weight loss

7 Slide 7 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Disorders of the Liver, Biliary Tract, Gallbladder, and Pancreas Cirrhosis (continued)  Clinical manifestations/assessment (continued) Late stages (continued)  Ascites  Enlarged spleen  Spider angiomas  Anemia  Bleeding tendencies  Epistaxis

8 Slide 8 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Disorders of the Liver, Biliary Tract, Gallbladder, and Pancreas Cirrhosis (continued)  Clinical manifestations/assessment (continued) Late stages (continued)  Purpura  Hematuria  Bleeding gums  Jaundice  Disorientation

9 Slide 9 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Figure 6-2 Systemic clinical manifestations of liver cirrhosis. (From Lewis, S.M., Heitkemper, M.M., Dirksen, S.R. [2007]. Medical-surgical nursing: assessment and management of clinical problems. [7 th ed.]. St. Louis: Mosby.)

10 Slide 10 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Disorders of the Liver, Biliary Tract, Gallbladder, and Pancreas Cirrhosis (continued)  Medical management/nursing interventions Pharmacological management  Antiemetics o Benadryl and Dramamine o Contraindicated: Vistaril, Compazine, and Atarax Eliminate the cause  Alcohol  Hepatotoxins  Environmental exposure to harmful chemicals

11 Slide 11 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Disorders of the Liver, Biliary Tract, Gallbladder, and Pancreas Cirrhosis (continued)  Medical management/nursing interventions (continued) Diet  Well-balanced  High in calories  Moderate in protein  Low in fat  Low in sodium  Supplemental vitamins and folic acid

12 Slide 12 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Disorders of the Liver, Biliary Tract, Gallbladder, and Pancreas Cirrhosis (continued)  Medical management/nursing interventions (continued) Treatment of complications  Ascites o Bed rest o Strict I&O o Restrict fluids and sodium o Diuretics: Aldactone, Lasix, HCTZ o Vitamins K, C, and folic acid supplements o LeVeen peritoneal-jugular shunt o Paracentesis

13 Slide 13 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Figure 6-3 LeVeen continuous peritoneal jugular shunt. (From Beare, P.G., Myers, J.L. [1998]. Adult health nursing. [3 rd ed.]. St. Louis: Mosby.)

14 Slide 14 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Disorders of the Liver, Biliary Tract, Gallbladder, and Pancreas Cirrhosis (continued)  Medical management/nursing interventions (continued) Treatment of complications (continued)  Ruptured esophageal varices o Maintain airway; establish IV o Vasopressin drip to control bleeding o Sengstaken-Blakemore tube o Endoscopic sclerotherapy o Portacaval shunt o Blood transfusion

15 Slide 15 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Disorders of the Liver, Biliary Tract, Gallbladder, and Pancreas Cirrhosis (continued)  Medical management/nursing interventions (continued) Treatment of complications (continued)  Hepatic encephalopathy o Decrease protein in diet o Avoid drugs that are detoxified by the liver o Lactulose o Neomycin

16 Slide 16 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Disorders of the Liver, Biliary Tract, Gallbladder, and Pancreas Liver cancer  Etiology and pathology Hepatocellular carcinoma most commonly seen Cirrhosis of the liver and hepatitis C and B are also elevated risk factors In the United States liver cancer is seen more in people over age 40 Metastatic carcinoma of the liver is seen more than primary liver cancer

17 Slide 17 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Disorders of the Liver, Biliary Tract, Gallbladder, and Pancreas Liver cancer  Clinical manifestations Hepatomegaly Weight loss Peripheral edema Ascites Portal hypertension Dull epigastric pain Jaundice Anorexia

18 Slide 18 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Disorders of the Liver, Biliary Tract, Gallbladder, and Pancreas Liver cancer  Diagnostic tests Liver scan Ultrasound CT scan Magnetic resonance imaging ERCP Liver biopsy

19 Slide 19 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Disorders of the Liver, Biliary Tract, Gallbladder, and Pancreas Liver cancer  Medical management/nursing interventions Palliative care Surgery Chemotherapy

20 Slide 20 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Disorders of the Liver, Biliary Tract, Gallbladder, and Pancreas Hepatitis  Etiology/pathophysiology Inflammation of the liver resulting from several types of viral agents or exposure to toxic substances Hepatitis A  Most common  Oral-fecal transmission

21 Slide 21 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Disorders of the Liver, Biliary Tract, Gallbladder, and Pancreas Hepatitis (continued)  Etiology/pathophysiology (continued) Hepatitis B  Transmission by contaminated serum; blood transfusion, contaminated needles, dialysis, or direct contact with infected body fluids Hepatitis C  Transmitted through contaminated needles and blood transfusions

22 Slide 22 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Disorders of the Liver, Biliary Tract, Gallbladder, and Pancreas Hepatitis (continued)  Etiology/pathophysiology (continued) Hepatitis D  Co-infection with hepatitis B Hepatitis E  Fecal contamination of water  Rare in the United States; usually in developing countries

23 Slide 23 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Disorders of the Liver, Biliary Tract, Gallbladder, and Pancreas Hepatitis (continued)  Clinical manifestations/assessment General malaise Aching muscles Photophobia Headaches Chills Abdominal pain Dyspepsia Nausea

24 Slide 24 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Disorders of the Liver, Biliary Tract, Gallbladder, and Pancreas Hepatitis (continued)  Clinical manifestations/assessment (continued) Diarrhea/constipation Pruritus Hepatomegaly Enlarged lymph nodes Weight loss Jaundice Dark amber urine Clay-colored stools

25 Slide 25 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Figure 6-5 Severe jaundice. (From Kamal, A., Brockelhurst, J.C. [1991]. Color atlas of geriatric medicine. [3 rd ed.]. St. Louis: Mosby-Year Book—Europe.)

26 Slide 26 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Disorders of the Liver, Biliary Tract, Gallbladder, and Pancreas Hepatitis (continued)  Medical management/nursing interventions Treat symptoms Small, frequent meals  Low-fat, high-carbohydrate IV fluids for dehydration Vitamin C, vitamin B–complex, vitamin K Avoid unnecessary medications, especially sedatives

27 Slide 27 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Disorders of the Liver, Biliary Tract, Gallbladder, and Pancreas Hepatitis (continued)  Medical management/nursing interventions (continued) Gamma globulin or immune serum globulin Hepatitis B immune globulin (HBIG)  Should be given to anyone exposed to hepatitis B Hepatitis B vaccine  Should be given to people identified as high risk for developing hepatitis B

28 Slide 28 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Disorders of the Liver, Biliary Tract, Gallbladder, and Pancreas Liver abscesses  Etiology/pathophysiology May be single or multiple Abscess forms in the liver due to invading bacteria

29 Slide 29 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Disorders of the Liver, Biliary Tract, Gallbladder, and Pancreas Liver abscesses (continued)  Clinical manifestations/assessment Fever Chills Abdominal pain and tenderness in the right upper quadrant Hepatomegaly Jaundice Anemia

30 Slide 30 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Disorders of the Liver, Biliary Tract, Gallbladder, and Pancreas Liver abscesses (continued)  Diagnostic tests Radiograph Ultrasound CT scan Liver scan  Medical management/nursing interventions IV antibiotic therapy Percutaneous drainage of liver abscess Open surgical drainage

31 Slide 31 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Disorders of the Liver, Biliary Tract, Gallbladder, and Pancreas Cholecystitis and cholelithiasis  Etiology/pathophysiology An obstruction, gallstone, or tumor prevents bile from leaving the gallbladder, and the trapped bile acts as an irritant, causing inflammation Risk factors  Female; American Indian or white; obesity; pregnancy; diabetes; multiparous women; use of birth control

32 Slide 32 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Figure 6-6 Common sites of gallstones. (from Monahan, F.D., et al. [2007]. Phipps’ medical-surgical nursing: health and illness perspectives. [8th ed.]. St. Louis: Mosby.)

33 Slide 33 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Disorders of the Liver, Biliary Tract, Gallbladder, and Pancreas Cholecystitis and cholelithiasis (continued)  Clinical manifestations/assessment Indigestion after eating foods high in fat Severe, colicky pain in the right upper quadrant Anorexia Nausea and vomiting Flatulence Increased heart and respiratory rates Diaphoresis

34 Slide 34 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Disorders of the Liver, Biliary Tract, Gallbladder, and Pancreas Cholecystitis and cholelithiasis (continued)  Clinical manifestations/assessment (continued) Low-grade fever Elevated WBC Mild jaundice Steatorrhea (fatty stool) Dark amber urine

35 Slide 35 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Disorders of the Liver, Biliary Tract, Gallbladder, and Pancreas Cholecystitis and cholelithiasis (continued)  Medical management/nursing interventions Mild attacks  Pharmacological management o Antispasmodic and analgesic medications o Antibiotics  Bed rest  NG tube to suction  NPO  IV fluids  Dietary recommendations: Avoid spicy foods when allowed PO intake

36 Slide 36 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Disorders of the Liver, Biliary Tract, Gallbladder, and Pancreas Cholecystitis and cholelithiasis (continued)  Medical management/nursing interventions (continued) Lithotripsy Cholecystectomy  Laparoscopic  Open

37 Slide 37 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Disorders of the Liver, Biliary Tract, Gallbladder, and Pancreas Pancreatitis  Etiology/pathophysiology Inflammation of the pancreas  Acute or chronic Predisposing factors  Alcohol  Trauma  Infectious disease  Certain drugs

38 Slide 38 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Disorders of the Liver, Biliary Tract, Gallbladder, and Pancreas Pancreatitis (continued)  Clinical manifestations/assessment Abdominal pain Anorexia; nausea and vomiting Malaise Low-grade fever Jaundice Weight loss Steatorrhea Tachycardia

39 Slide 39 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Disorders of the Liver, Biliary Tract, Gallbladder, and Pancreas Pancreatitis (continued)  Medical management/nursing interventions Pharmacological management  Antiemetics  Analgesics  Anticholinergics  Antacids NPO IV fluids NG tube Hyperalimentation

40 Slide 40 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Disorders of the Liver, Biliary Tract, Gallbladder, and Pancreas Cancer of the pancreas  Etiology/pathophysiology Unknown Risk factors  Cigarette smoking; exposure to chemical carcinogens; diabetes mellitus; pancreatitis; diet high in meat, fat, and coffee May be metastasis from the lung, stomach, duodenum, or common bile duct (CBD) May live only 4 to 8 months after diagnosis

41 Slide 41 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Disorders of the Liver, Biliary Tract, Gallbladder, and Pancreas Cancer of the pancreas (continued)  Clinical manifestations/assessment Anorexia Fatigue Nausea and flatulence Change in stools Steady, dull, aching pain in the epigastric area Weight loss Jaundice Onset of diabetes mellitus

42 Slide 42 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Disorders of the Liver, Biliary Tract, Gallbladder, and Pancreas Cancer of the pancreas (continued)  Medical management/nursing interventions Surgery  Whipple procedure  Total pancreatectomy with resection of parts of the GI tract Chemotherapy Radiation

43 Slide 43 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Figure 6-9 Whipple’s procedure, or radical pancreaticoduodenectomy. (From Lewis, S.M., Heitkemper, M.M., Dirksen, S.R. [2007]. Medical-surgical nursing: assessment and management of clinical problems. [7 th ed.]. St. Louis: Mosby.)

44 Slide 44 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Nursing Process Nursing diagnoses  Activity intolerance  Breathing pattern, ineffective  Fluid volume, deficient  Home maintenance, impaired  Injury, risk for  Knowledge, deficient  Noncompliance  Nutrition, imbalanced, less than body requirements  Pain, acute/chronic  Powerlessness  Skin integrity, impaired  Thought processes, disturbed


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