2 OBJECTIVES Discus management of patient with cholelithiasis. Use the nursing process a framework for care of –patients with cholelithiasis and undergoing laparoscopic or open cholecystectomy.Differentiate between acute and chronic pancreatitis.Describe the nursing management of patients with acute pancreatitis.
3 GALLBLADDER Pear shaped organ Stores 30-50 mL of bile Collects, concentrates and stores bile until needed for digestion.Releases bile into the duodenum via the common bile duct when fat is present.
5 BILIARY CONDITIONS Extremely common Interfere with the normal drainage of bile into the duodenum2 common problems:a. Cholecystitisb. CholelithiasisCommon in Caucasians/Native AmericansBiliary conditions occur extremely commonly, and interfere with the normal drainage of bile into the duodenum. If bile does not flow into the duodenum, bilirubin does not enter the intestines, fat emulsification cannot occur, there is increased renal excretion of bilirubin and decreased excretion in the stools.The 2 most common biliary complications are cholecystitis (inflammation of the gallbladder) and cholelithiasis (gallstones). These usually occur together.These complications are seen more in Caucasians and Native Americans, and seen more in women, especially multiparous and over age 40.
6 Risk FactorsSedentary lifestyleObesityMultiparous women
7 CHOLECYSTITIS Acute inflammation of the gallbladder May result from stones may obstructing the outflow of bileS/S pain in the ® upper abdomen that may radiate to the ® shoulder, tenderness, rigidity ® upper abdomenCholecystitis is an acute inflammation of the gallbladder, that may result from gallstones obstructing the outflow of bile, from biliary sludge (broken down gallstones), or from neoplasms. The inflammation may be limited to the mucus lining, or may be the entire wall of the gallbladder.The clinical manifestations vary from indigestion up to moderate or severe pain. In acute cholecystitis complaints of pain and tenderness in the right upper quadrant of the abdomen that may radiate to the right shoulder and scapula. You will see right upper quadrant tenderness and abdominal rigidity. Nausea and vomiting may be present; restlessness, diaphoresis, fever.
8 CHOLECYSTITIS Acalculous Gallbladder inflammation without gallstones/absence of obstructionOccurs after major surgical procedures, severe trauma & extensive burnsAcalculous cholecystitis is gallbladder inflammation that occurs in the absence of gallstones or obstruction. This can occur in older adults, trauma victims, from extensive burns, or recent surgery
9 CHOLECYSTITIS Calculous Gallbladder inflammation & stones that obstruct bile flowOccurs in 90% of the clientsCalculous cholecystitis occurs when there is inflammation along with stones obstructing the bile flow. 90% of clients with cholecystitis have calculous cholecystitis.
10 CHOLELITHIASIS Calculi/gallstones— form from the solid constituents of bilevary greatly in size, shape & compositionincreasing prevalent after 40 yrs. of age; esp. womenCalculi or gallstones form from the solid constituents of bile. The cause is unknown. Cholesterol, bile salts, and calcium precipitate to form stones; stasis of bile can also lead to stone formation. The stones vary in size, shape and composition; the stones remain in the gallbladder, or migrate to the cystic ducts or the common bile duct. Gallstones are prevalent in the over 40 cohort, especially in women.
11 GALLSTONESA pictorial representation of cholelithiasis.
12 PATHOPHYSIOLOGY Two major types of gallstones: Pigment Stones Cholesterol StonesTwo major types of gallstones are: pigment stones composed of calcium bilirubinate. These cannot be dissolved and must be removed surgically. These are seen in 25% of all cases in the USA.Cholesterol stones are composed of….cholesterol!
13 CHOLESTEROL STONES Account for 80% of gallbladder disease . There is a decrease in bile salts & an increase in cholesterol.Cholesterol saturated bile causes gallstones.This acts as an irritant that produces inflammatory changes in the gallbladder.75-80% of all gallbladder disease is caused by cholesterol stones. In gallstone prone patients there is increased bile supersaturated with cholesterol; the cholesterol precipitates out forming stones. The gallstone act as irritants, producing inflammation of the gallbladder and its structures.
14 CHOLESTEROL STONES Are 2-3x more common in women. Incidence increases with clients with diabetes.Stones are usually smooth & are whitish yellow to tan in color.Gallstones are 2-3 times more common in women. Stone formation incidence is greater in clients using medications known to increase biliary cholesterol, such as oral contraceptives, estrogens, and clofibrate. Diabetics are also more prone to stones.The cholesterol gallstones are usually smooth, and appear whitish yellow to tan in color.
16 CLINICAL MANIFESTATIONS Clinical manifestations of gallstones range from no symptoms to excruciating pain. The severity of the pain depends on if the stones are stationary or mobile, and if they are obstructive or not.
17 PAIN/BILIARY COLIC Classic symptom Spasms occur in order to move the stone through the duct.Excruciating ® upper abdominal painMay occur 3-6 hours after a heavy mealMay require analgesics meperidineThe classic symptom of cholelithiasis is pain (also known as biliary colic) caused by spasms trying to move the stones through the duct. Patients can complain of excruciating pain in the right upper abdomen. Tachycardia and diaphoresis may also be noted with the pain and spasms.The spasms and pain may last up to 1 hour, with residual tenderness in the right upper quadrant noted afterwards. These attacks often occur 3-6 hours after a large meal. The pain may be so severe that analgesics are required; meperidine (Demerol) is generally the drug of choice.
18 JAUNDICEAppears when the Common Bile Duct (CBD) obstruction is present.Bile is no longer carried to the duodenum– absorbed in the blood.PruritusConcentration of bilirubin > 2.5Jaundice appears when the common bile duct is obstructed. Bile, usually carried to the duodenum, but now blocked, is absorbed into the blood. The bile in the blood stream deposits in the skin and mucous membranes, giving the skin and mucous membranes a yellow color. The build up of bile is often accompanied by pruritis, and lab values will indicate a bilirubin of greater than 2.5.
19 VITAMIN DEFICIENCYObstruction of bile flow interferes with absorption of fat soluble vitamins intestines.Vitamin A, D, E, K, deficiencies may be seen.Obstruction of bile flow also interferes with the absorption of fat soluble vitamins in the intestines, leading to deficiencies in vit. A, D, E, and K.
20 CHANGES in URINE & STOOL COLOR Urine takes on a very dark color.Stool no longer with bile pigmentsWith a total obstruction amber urine is seen (increased renal excretion of bilirubin); bile pigments are absent in the stool, leading to a clay colored or grayish color.
21 DIAGNOSTIC FINDINGS Abdominal x-ray Ultrasonography Endoscopic Retrograde Cholangiopancreatography – ERCP* nursing implicationsDiagnostic exams for cholelithiasis are:Abdominal x-rayAbdominal ultrasoundEndoscopic Retrograde Cholangiopancreatography (better known, and more easily referred to, as ERCP).
22 ERCPFlexible fiberoptic endoscope that allows for visualization of the hepatobiliary system/place stents.90% of the clients do well with this procedure.The stone may be extracted or left in the duodenum to pass naturally.The ERCP is done with a flexible fiberoptic endoscope that allows for visualization of the gallbladder, cystic duct, common hepatic duct and the common bile duct. In addition to visualization, placement of stents to widen the ducts can be done with ERCP, as well as sphincterotomy, which widens the duct, and allows for the stone to be grabbed with a basket.The stones may either be removed during the ERCP or allowed to pass normally through the duodenum.
26 MEDICAL MANAGEMENT Major Objective: Reduce the episode of gallbladder pain & inflammation by supportive & dietary management.Remove the cause of cholecystitis by pharmacological therapy, endoscopic procedures or surgical interventions.The goal of treatment is to provide pain relief before the pain is severe, and try to decrease the inflammation using supportive therapy and dietary management, and to prevent recurrence of attacks. The immediate management goal is to remove the cause of cholecystitis using pharmacologic therapies, endoscopic procedures or surgical interventions.
27 NUTRITIONAL & SUPPORTIVE THERAPY Low- fat dietFoods to avoidRemind client that fatty foods may bring on an episode of cholecystitis.Nutritional therapy-provide patient teaching about following a low fat and low calorie diet, and eat small, frequent meals. Avoid those foods high in cholesterol and fats. While fat tolerance depends on the individual patient, it is important to stress to the client that fatty foods can lead to irritation, stone formation, and episodes of cholecystitis.
28 PHARMACOLOGIC THERAPY Cholestyramine (Questran)Urosdeoxycholic acid (Actigall) & Chenodiol (Chenix) are medications used to dissolve small gallstones/composed of primarily cholesterol .6-12 months of therapy is required to dissolve stones.Indicated for clients who refuse surgery/surgery is to risky.Drug therapy: during acute episodes, pain controlled with analgesics (meperidine). Anticholinergics like atropine are given to relax smooth muscles.Questran binds with bile salts, increasing the excretion in the feces, and helping to avoid stone formation.Urosdeoxycholic acid (UDCA) and Chenodial (CDCA) are medications that are used as stone dissolvers. These are long term therapies, taking from 6 to 12 (or 24) months to dissolve the stones. These medications are used for patients who are unwilling or unable to have surgical therapy.
29 NONSURGICAL REMOVAL of GALLSTONES Extracorporal Shock Wave LithotripsyNoninvasive procedureUses repeated shock waves to disintegrate gallstones.Requires no incision & no hospitalization.Has been replaced – Laproscopic CholecystectomyOther non-surgical interventions include Extracorporal Shock Wave Lithotripsy (ESWL). High energy shock waves are used to disintegrate the stones. Ultrasound is used to locate the stones, and the shock waves are directed at the stones to help break them up. The procedure may take 1-2 hours to break up the stones. This is seen less often since laproscopic cholecystectomies have been performed.
31 SURGICAL MANAGEMENT Done to: Relieve persistent symptoms Remove the cause of the biliary colicTreat acute cholecystitisSurgical therapy is the cholecystectomy (removal of the gallbladder) done in cases where it is necessary to relieve persistent symptoms, to remove the cause of the biliary colic, and/or to treat acute cholecystitis.
32 LAPROSCOPIC CHOLECYSTECTOMY Standard of care for Rx. of gallstones.Small incision is made through the abdominal wall at the umbilicus.4 small incisions are made through the abd. wall to introduce other surgical instruments.Abdomen is insufflated with carbon dioxide – assists in visualizing abd. structures.The laproscopic cholecystectomy has become the new standard of care for the treatment of gallstones. A small incision is made through the abdominal wall at the umbilicus, followed by an additional 4 small incisions to allow the surgical instruments in. The abdomen is insufflated with carbon dioxide to assist in the visualization of the abdominal structures. The gallbladder is removed through the small abdominal incision.
33 LAPROSCOPIC CHOLECYSTECTOMY Advantages :Short hospital stayLess invasive /shorter healing timeLess post-op pain/less opiod useEarly ambulationAble to resume full activity in about 3-4 days.Incision care is minimalThe advantages of the laproscopic cholecystectomy is that it allows for the patient to be discharged from the hospital on the day of surgery or the following day; it is a less invasive procedure, requiring less time to heal. There is less complaint of pain post-operatively, leading to less use of opioid analgesics. The patient is able to ambulate earlier, and generally able to resume full activity in about 3-4 days. The incisional care is minimal, with the dressings generally consisting of small band-aids over the incision sites and a DSD/bandaid on the umbilicus.Drawbacks include potential for injury to the common bile duct; and often a complaint of shoulder pain resulting from the build-up of CO2 in the body from the insufflation.
35 We will now discuss the traditional or Open cholecystectomy procedure We will now discuss the traditional or Open cholecystectomy procedure. As you can see from this comparison, there is quite a difference between the laproscopic and open cholecystectomy procedure. Laproscopic procedures are the preferred method now, unless the gallbladder is too large, edematous, or unable to be removed in that fashion.
36 CHOLECYSTECTOMY Gallbladder is removed through abdominal incision. Drain may be placed – near the gall bladder bed & brought out through a puncture site for drainage.Drain usually kept in placed for 24 hrs. then removed.In an open cholecystectomy the gallbladder is removed through a right subcostal incision in the abdomen. A drain is often placed near the gallbladder bed, and brought out for drainage; the drain is usually maintained in place for around 24 hours, and then removed.A T-tube may be inserted into the common bile duct to ensure patency of the duct until the edema subsides.
37 CHOLECYSTECTOMY Post-op Nursing Interventions: Relieve the pain Improve the respiratory statusImprove the nutritional statusSkin integrity/drainagePost-operatively the nursing interventions focus on comfort to relieve pain. After a laproscopic cholecystectomy, the patient may need to be in Sims position, on the left side with right knees flexed to relieve the pain from the CO2 that was not absorbed by the body. Provide analgesics – oxycodone or codeine.Deep breathing and coughing exercises – teach splinting for all post-op patients. Ensure adequate ventilation, improve respiratory status (don’t forget the incentive spirometer!).Improve the patient’s nutritional status – progress from clear liquids to solid foods, and teach about importance of eating small, frequent, nutritious foods (low fat/low calorie).If there are any drains, monitor drainage from T-tube, Jackson-Pratt or Penrose drains.And, of course, monitor for any bleeding!
38 NURSING INTERVENTION Fowler’s position May have NGT NPO until bowel sounds return, then a soft, low-fat, low-carbohydrate, high protein diet postoperativelyCare of biliary drainage systemAdminister analgesics as ordered and medicate to promote/permit ambulation and activities, including deep breathingTurn, and encourage coughing and deep breathing, splinting to reduce painAmbulation
39 Patient Teaching Medications Diet: at discharge, maintain a nutritious diet and avoid excess fat. Fat restriction is usually lifted in 4–6 weeks.Instruct in wound care, dressing changes, care of T-tubeInstruct patient and family to report signs of gastrointestinal complications, changes in color of stool or urine, fever, unrelieved or increased pain, nausea, vomiting, and redness/edema/signs of infection at incision site
41 PANCREAS Located in upper abdomen Functions Exocrine function Secrete digestive enzymes into the GI tract through the pancreatic duct.Amylase, trypsin, lipaseEndocrine functionsecretes insulin, glucagon, and somatostatin directly into the blood stream
42 PancreatitisCharacterized by the release of pancreatic enzymes into the tissue of the pancreas itself hemorrhage and necrosisCan be acute or chronicHospitalizations for acute pancreatitis have increase over the last 15 yearsAlcoholism and gall stones are the primary risk factors.
43 Acute PancreatitisThe pancreatic duct becomes obstructed and enzymes back up into the duct, causing auto digestion and inflammation of the pancreas.Minimal organ dysfunction is present.Characterized by edema and inflammation which is confined to the pancreas.Affects all ages – common in middle-aged men/women3x higher in Afro-Americans than Caucasians
44 Risk Factors Gallstones – leading cause Alcoholism Trauma Infection -- viral
45 Acute PancreatitisSelf- digestion of the pancreas by its own enzymes especially trypsin.This causes injury to the pancreatic cells or activation of the pancreatic enzymes in the pancreas rather than the intestines.Activated trypsin is in the pancreas. This enzyme can digest the pancreas and can activate other proteolytic enzymes.
46 Acute Pancreatitis Clinical Manifestations Abdominal pain Pain not relieved not by vomitingAbdominal tenderness with muscle guardingBowel sounds may be absent/diminishedHypotension, fever, jaundice
47 Acute Pancreatitis Assessment/Diagnostic Findings Serum amylase and lipase levels increasedOther findings – increase in liver enzymes, bilirubin, triglycerides .X-rays of the chest and abdomenAbdominal ultrasound
50 Acute Pancreatitis Nursing Management Improve nutritional statusOral food/fluid intake in not permitted.Monitor lab results/daily weightsAvoid heavy meals/alcoholic beveragesDiet – high CHO, low fats, low proteins.
51 CHRONIC PANCREATITISProgressive inflammatory disorder with destruction of the pancreas.Cells are replaced by fibrous tissue.Repeated attacks of pancreatitis occur that increase pressure within the pancreas.Obstruction of the pancreatic and common bile ducts and destruction of the secreting cells of the pancreas occur.
52 CHRONIC PANCREATITIS Etiology Excessive and prolonged alcohol consumptionMalnutritionMedian age years old
53 PANCREATITISchronicacuteSevere abdominal painPatient appears acutely illAbdominal guardingNausea and vomitingFever, jaundice, confusion, and agitation may occurEcchymosis in the flank or umbilical area may occurMay develop respiratory distress, hypoxia, renal failure, hypovolemia, and shockRecurrent attacks of severe upper abdominal and back pain accompanied by vomitingWeight lossSteatorrhea
54 Chronic Pancreatitis Assessment /Diagnostic Findings Serum lipase and amylase slightly elevatedSerum bilirubin increasedERCP makes the diagnosisStool samples
55 Chronic Pancreatitis Goals Prevent further attacks Relief of pain Control of pancreatic endocrine/exocrine insufficiency