1. Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. Care of Patients with Disorders of the Gallbladder, Liver, and Pancreas

2. Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. Theory Objectives Explain the plan of care for the patient with cholelithiasis. Describe treatment for the patient with cholecystitis. List the ways in which the various types of hepatitis can be transmitted. Identify signs and symptoms of the various types of hepatitis. 1

3. Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. Theory Objectives (cont.) Devise appropriate nursing interventions for the patient with cirrhosis and ascites. Indicate potential causes of liver failure. Differentiate the signs and symptoms of acute and chronic liver failure. Describe the postoperative care of the patient who has undergone a liver transplantation. 2

4. Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. Theory Objectives (cont.) Devise a nursing care plan for the patient with cancer of the liver. Prepare a plan for adequate pain control for the patient with pancreatitis. Compare the treatment options for cancer of the pancreas. 3

5. Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. Clinical Practice Objectives Perform preoperative teaching for a patient who is to undergo laparoscopic cholecystectomy. Write a nursing care plan, including psychosocial concerns, for the patient who has hepatitis with jaundice. Design a discharge teaching plan for the patient who has been in the hospital with a flare-up of chronic pancreatitis. 4

6. Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. Cholelithiasis and Cholecystitis Etiology Ethnic predisposition to gallstones Pathophysiology Signs and symptoms None to severe and unbearable pain Chronic cholecystitis is biliary colic 5

7. Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. Gallstones 6

8. Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. Cholelithiasis and Cholecystitis Diagnosis Ultrasonography Computed tomography (CT) Endoscopic retrograde cholangiopancreatography (ERCP) Cholescintigraphy (hepatoiminodiacetic acid [HIDA] scan) Liver function tests 7

9. Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. Comparison of Symptoms of Gallbladder Disorders Pain/biliary colic Nausea, vomiting Indigestion and flatulence Low-grade fever Jaundice 8

10. Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. Cholelithiasis and Cholecystitis Treatment Diet Correction of bile obstruction Antibiotics Post-cholecystectomy diet Surgery Complications 9

11. Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. Postoperative Laparoscopic Cholecystectomy Remove the bandages from the puncture sites the day after surgery and shower Report the following signs and symptoms should they occur: redness, swelling, bile-colored drainage or pus from any surgical site, severe abdominal pain, nausea, vomiting, chills, or fever, light-colored stool, dark urine, or yellow tint to the eyes or skin, as these signs may indicate obstruction of the flow of bile 10

12. Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. Postoperative Laparoscopic Cholecystectomy (cont.) Normal activities may be resumed gradually Return to work is probable at 1 week postsurgery Stick to a low-fat diet for several weeks, slowly introduce fattier foods to determine if these cause unpleasant symptoms 11

13. Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. Nursing Management Preoperative care Postoperative care Caring for a T-tube 12

14. Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. T-Tube 13

15. Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. Hepatitis Etiology and pathophysiology Types of viral hepatitis HBV among Asian Americans Signs and symptoms Pre-icteric phase Icteric phase Post-icteric phase Complications 14

16. Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. Comparison of Hepatitis-Causing Viruses Transmission modes Incubation periods Infective periods Signs and symptoms 15

17. Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. Diagnosis of Hepatitis Serologic assays or enzyme immunoassays (EIAs) Liver biopsy Elevations in liver function tests (LFTs) 16

18. Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. Laboratory Tests Aspartate aminotransferase (AST) Alanine aminotransferase (ALT) Gamma-glutamyl transpeptidase (GGT) Bilirubin Alkaline phosphatase Serum albumin Serum bilirubin (total) Prothrombin time 17

19. Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. Treatment of Hepatitis There is no specific treatment for acute viral hepatitis Non-drug measures include well-balanced diet and rest, avoiding hepatotoxic substances including alcohol and certain medications Active and passive immunity Antiviral therapy 18

20. Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. Expected Outcomes Patient will maintain body weight within normal limits during illness Patient will verbalize lessened fatigue after rest periods each day Patient will verbalize a decrease in pain after institution of nursing measures to decrease discomforts 19

21. Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. Expected Outcomes (cont.) Patient will verbalize knowledge of disease process and self-care within 2 days Patient will engage in appropriate diversional activities during convalescence 20

22. Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. Nursing Interventions Monitor progress Prevent the spread of infection Patient/family teaching — proper handling of body secretions, proper hand hygiene, and limiting contact Psychological support Ensure adequate nutrition 21

23. Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. Prevention of Hepatitis Home considerations for different types of viral hepatitis Standard Precautions guidelines Infection control 22

24. Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. Cirrhosis Etiology Postnecrotic cirrhosis Laënnec’s cirrhosis or portal cirrhosis Biliary cirrhosis Cardiac cirrhosis Liver-related deaths 23

25. Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. Cirrhosis (cont.) Diagnosis Liver biopsy Liver function studies CT and liver scan Magnetic resonance cholangiopancreatography Treatment — stopping the liver damage and restoring the liver’s functions 24

26. Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. Signs and Symptoms Subjective symptoms Fatigue Weakness Headache Anorexia Indigestion Abdominal pain Nausea Vomiting 25

27. Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. Signs and Symptoms (cont.) Fluid retention in the right hemithorax or ascites can limit expansion of the chest and cause dyspnea Objective symptoms of liver cirrhosis include excessive gas, skin rashes, itching, and fever Leg and foot edema and palmar erythema Caput medusa Bleeding and bruising 26

28. Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. Signs and Symptoms (cont.) Deficiencies in vitamin K, thrombin, or prothrombin interfere with clot formation The liver often is enlarged and “knobby” and is palpable below the level of the right rib cage Abdominal distention The spleen also enlarges 27

29. Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. Signs and Symptoms (cont.) Peripheral edema and ascites Skin lesions, jaundice, pruritus, bleeding disorders, endocrine disorders, and peripheral neuropathy occur in late disease Spider angiomas may appear on the face, neck, upper trunk, and arms The angiomas may blanch with pressure 28

30. Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. Signs and Symptoms of Cirrhosis 29

31. Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. Relationship of Systemic Portal Hypertension and Ascites in Cirrhosis 30

32. Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. Nursing Management of Cirrhosis Assessment Assess for safety issues Laboratory tests Alcohol withdrawal Nursing diagnosis Planning and implementation Evaluation 31

33. Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. Complications of Cirrhosis Esophageal varices Encephalopathy Delirium, convulsions, asterixis, and coma Fetor hepaticus 32

34. Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. Blakemore-Sengstaken Tube 33

35. Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. Liver Transplantation Legal and ethical considerations Nursing management Care of drains Immunosuppressants Liver function monitoring 34

36. Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. Cancer of the Liver Etiology Pathophysiology Signs and symptoms Diagnosis Treatment Nursing management 35

37. Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. Acute Pancreatitis Etiology Pathophysiology Signs and symptoms Diagnosis Treatment Nursing management 36

38. Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. Chronic Pancreatitis Etiology and pathophysiology Signs and symptoms Diagnosis Determination of bicarbonate concentration and output in the duodenum after stimulation with secretin is the definitive test for chronic pancreatitis 37

39. Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. Chronic Pancreatitis (cont.) Treatment Nursing management Pain management Complications including diabetes mellitus Avoid alcohol 38

40. Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. Pathophysiology of Acute Pancreatitis 39

41. Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. Cancer of the Pancreas Etiology Pancreatic cancer deaths Healthy gums for better pancreatic health Pathophysiology Cigarette smoking Adenocarcinoma Tumor in the head of the pancreas Tumor in the body and tail of pancreas 40

42. Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. Cancer of the Pancreas (cont.) Signs and symptoms Deep vein thrombosis Diagnosis Ultrasonography, imaging techniques, and fine-needle biopsy Elevated carcinoembryonic antigen levels Serum beta-human chorionic gonadotropin and carbohydrate antigen (CA) 72-4 Tumor markers CA 19-9 and CA 242 41

43. Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. Cancer of the Pancreas (cont.) Treatment Keep the patient comfortable Treat or prevent malnutrition Surgical treatment including Whipple procedure, or radical pancreaticoduodenectomy Other treatments Nursing management Community care 42

44. Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. Audience Response Question 1 The nurse caring for a patient who has undergone radical pancreaticoduodenectomy should monitor for which postoperative complication(s)? (Select all that apply.) 1. Hypoglycemia 2. Hemorrhage 3. Bowel obstruction 4. Intra-abdominal abscess 5. Hyperkalemia 43