1. Chapter 30 Care of Patients with Disorders of the Liver, Gallbladder, and Pancreas Medical-Surgical Nursing: Concepts & Practice 3 rd edition Copyright © 2017, Elsevier Inc. All rights reserved.

2.  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.  Devise appropriate nursing interventions for the patient with cirrhosis and ascites.  Indicate potential causes of liver failure. 2 Theory Objectives

3. Copyright © 2017, Elsevier Inc. All rights reserved.  Differentiate the signs and symptoms of acute and chronic liver failure.  Discuss the criteria used for selection of liver transplantation recipients.  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 Theory Objectives (Cont.)

4. Copyright © 2017, Elsevier Inc. All rights reserved.  Perform preoperative teaching for a patient who is to undergo laparoscopic cholecystectomy.  Review a nursing care plan, including psychosocial concerns, for the patient who has hepatitis with jaundice.  Implement a discharge teaching plan for the patient who has been in the hospital with a flare-up of chronic pancreatitis. 4 Clinical Practice Objectives

5. Copyright © 2017, Elsevier Inc. All rights reserved. Cholelithiasis (gallstones) and Cholecystitis(Inflammation of Gallbladder)  Etiology  Ethnic predisposition to gallstones (Native Americans and Hispanic Americans) high cholesterol diets  Pathophysiology – stones may obstruct bile flow  Signs and symptoms  None to severe and unbearable pain  N&V, fever, leukocytosis, jaundice  Unbearable upper right quadrant pain (bilary colic) 5

6. Copyright © 2017, Elsevier Inc. All rights reserved. Gallstones – page 695 6

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8. Copyright © 2017, Elsevier Inc. All rights reserved. Cholelithiasis and Cholecystitis  Diagnosis  Ultrasonography of gallbladder and biliary tract  Computed tomography (CT)  Endoscopic retrograde cholangiopancreatography (ERCP)  Cholescintigraphy (hepatoiminodiacetic acid [HIDA] scan)  Liver function tests and WBC elevation and sedimentation rate 8

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10. Copyright © 2017, Elsevier Inc. All rights reserved. Cholelithiasis and Cholecystitis  Treatment  Low Fat Diet, weight loss, restrict alcohol intake, small meals, oral medications that reduce gallstones  Correction of bile obstruction by ERCP to remove stones  Antibiotics only if peritonitis is present  Post-cholecystectomy diet  Surgery – U.S 90% laparoscopic  Complications – internal bleeding, abdominal rigidity 10

11. gallstones 11

12. Copyright © 2017, Elsevier Inc. All rights reserved. Postoperative Laparoscopic Cholecystectomy  Remove the bandages from the puncture sites the day after surgery and shower.  Report the following signs and symptoms if 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 because these signs may indicate obstruction of the flow of bile. 12

13. Copyright © 2017, Elsevier Inc. All rights reserved. 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. 13

14. Gallbladder Disease Cholecystitis 14

15. Copyright © 2017, Elsevier Inc. All rights reserved. Nursing Management for Gallbladder Surgery  Preoperative care – NPO, antiemetics for nausea or NG tube, IV fluids  Postoperative care – Semi-Fowlers, deep breathing and coughing  Caring for a T-tube – patient may have tubes or drains if continuing drainage is expected. Dressing absorb. Change frequently. If fresh blood appears, contact surgeon. Stool should be brown (bile), if light color bile is obstructed 15

16. Copyright © 2017, Elsevier Inc. All rights reserved. Hepatitis  Etiology and pathophysiology  Types of viral hepatitis – page 698 Table 30-2  Liver cells are damaged  Hep B and C are the most serious forms of hepatitis, often progressing to chronic hepatitis, liver cancer and death  Signs and symptoms – depend on the type of hepatitis – see page 699  Diagnosis – hx, physical and labwork (table 30-3 pg 700) 16

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18. Hepatitis  Treatment- rest to help the liver to regenerate, small meals, Zofran for nausea, antivirals medications,  HEPATITIS IS AN OCCUPATIONAL HAZARD FOR ALL PEOLE WHO HAVE DIRECT CONTACT WITH PATIENTS. STANDARD PRECAUTIONS MUST BE OBSERVED AT ALL TIMES. 18

19. Copyright © 2017, Elsevier Inc. All rights reserved. Treatment of Hepatitis  There is no specific treatment for acute viral hepatitis.  Nondrug measures include a well-balanced diet and rest and avoiding hepatotoxic substances, including alcohol and certain medications.  Active and passive immunity  Antiviral therapy 19

20. Copyright © 2017, Elsevier Inc. All rights reserved. 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. 20

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22. Copyright © 2017, Elsevier Inc. All rights reserved. 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. 22

23. Copyright © 2017, Elsevier Inc. All rights reserved. Nursing Interventions  Monitor progress.  Prevent the spread of infection.  Patient and family teaching—proper handling of body secretions, proper hand hygiene, and limiting contact  Psychological support  Ensure adequate nutrition 23

24. Copyright © 2017, Elsevier Inc. All rights reserved. Cirrhosis- Chronic Disease of the Liver  Etiology -  Postnecrotic cirrhosis – viral hepatitis, toxic substances, parasites or infection  Laënnec’s cirrhosis or portal cirrhosis - alcohol  Biliary cirrhosis – chronic biliary obstruction  Cardiac cirrhosis – right sided heart failure  ALCOHOLISM CAUSES DEPOSITION OF FAT IN THE LIVER CELLS. THIS IS REVERSABLE IF ALCOHOL CONSUMPTION IS HALTED 24

25. Copyright © 2017, Elsevier Inc. All rights reserved. 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 25

26. Copyright © 2017, Elsevier Inc. All rights reserved.  Subjective symptoms  Fatigue  Weakness  Headache  Anorexia  Indigestion  Abdominal pain  Nausea  Vomiting 26 Signs and Symptoms

27. Copyright © 2017, Elsevier Inc. All rights reserved.  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 (redness of palms)  Caput medusa (blue varicose veins around umbilicus)  Bleeding and bruising, urine dark, jaundice 27 Signs and Symptoms (Cont.)

28. Copyright © 2017, Elsevier Inc. All rights reserved.  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. 28 Signs and Symptoms (Cont.)

29. Copyright © 2017, Elsevier Inc. All rights reserved. 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.  Elevations in liver enzymes usually do not occur until 65% of liver function is gone. 29

30. Copyright © 2017, Elsevier Inc. All rights reserved. Signs and Symptoms of Cirrhosis 30

31. Copyright © 2017, Elsevier Inc. All rights reserved. Relationship of Systemic Portal Hypertension and Ascites in Cirrhosis 31

32. Copyright © 2017, Elsevier Inc. All rights reserved. Nursing Management of Cirrhosis  Assessment  Assess for safety issues  Laboratory tests  Alcohol withdrawal  Nursing diagnosis  Planning and implementation  Evaluation 32

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34. Copyright © 2017, Elsevier Inc. All rights reserved. Complications of Cirrhosis  Esophageal varices – engorged veins from portal congestion and hypertension, if vein walls rupture, massive bleeding  Encephalopathy  Delirium, convulsions, asterixis (tremors), and coma  Fetor hepaticus (breath with a sweet, fecal odor) 34

35. Copyright © 2017, Elsevier Inc. All rights reserved. Treatment for Esophageal Varices – page 711 35

36. Copyright © 2017, Elsevier Inc. All rights reserved. Liver Transplantation  Legal and ethical considerations  Nursing management  Care of drains  Immunosuppressants  Liver function monitoring 36

37. Copyright © 2017, Elsevier Inc. All rights reserved. Cancer of the Liver  Etiology – usually metastatic  Pathophysiology – cirrhosis or hepatitis b or c increase the risk, inflammation of normal liver cells  Signs and symptoms – right upper quadrant pain, fatigue, weight loss  Diagnosis - labwork, biopsy  Treatment – radiation and chemotherapy 37

38. Liver cancer 38

39. Copyright © 2017, Elsevier Inc. All rights reserved. Acute Pancreatitis  Etiology – alcoholism, trauma, viral infections  Pathophysiology – inflammation/damage caused by the escape of pancreatic digestive enzymes  Signs and symptoms- abdominal pain left upper quadrant, eating makes the pain worse  Diagnosis –symptoms, ultrasound, CT, labwork  Treatment – pain management, fluids, nutritional support 39

40. Copyright © 2017, Elsevier Inc. All rights reserved. Chronic Pancreatitis  Etiology and pathophysiology – repeated bouts of inflammation causes progressive fibrosis of the gland, stricture of the ducts and eventual calcification  Signs and symptoms – abdominal pain, malabsorption with weight loss  Diagnosis  Determination of bicarbonate concentration and output in the duodenum after stimulation with secretin is the definitive test for chronic pancreatitis. 40

41. Copyright © 2017, Elsevier Inc. All rights reserved. Chronic Pancreatitis (Cont.)  Treatment and Nursing management  Pain management  Complications, including diabetes mellitus  Avoid alcohol. 41

42. Chronic Pancreatitis 42

43. Copyright © 2017, Elsevier Inc. All rights reserved. Cancer of the Pancreas  Signs and symptoms epigastric pain and weight loss. High incidence of clot formation  Deep vein thrombosis  Diagnosis  Ultrasonography, imaging techniques, and fine-needle biopsy  Elevated carcinoembryonic antigen levels elevated 80 to 90%  Serum beta-human chorionic gonadotropin and carbohydrate antigen (CA) 72-4  Tumor markers CA 19-9 and CA 242 43

44. Copyright © 2017, Elsevier Inc. All rights reserved. Cancer of the Pancreas (Cont.)  Treatment  Keep the patient comfortable.  Treat or prevent malnutrition.  Surgical treatment, including Whipple procedure ( head of pancreas, the gallbladder, the duodenum, part of the jejunum and all or part of the stomach are removed), or radical pancreaticoduodenectomy  Other treatments – ablation, microwave therapy  Nursing management – manage pain (page 716)  Community care – promote immunizations 44