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

2. Cholelithiasis and Cholecystitis
Etiology
Ethnic predisposition to gallstones
Pathophysiology
Signs and symptoms
None to severe and unbearable pain
Chronic cholecystitis is biliary colic

3. Risk factors Female High-fat diet Obesity
Age and genetic predisposition
Type 2 diabetes rapid weight loss (increases cholesterol)

4. Gallstones
See Figure 30-1 on p. 695.

7. Cholelithiasis and Cholecystitis
Diagnosis
Ultrasonography
Computed tomography (CT)
Endoscopic retrograde cholangiopancreatography (ERCP)
Cholescintigraphy (hepatoiminodiacetic acid [HIDA] scan)
Liver function tests

8. Comparison of Symptoms of Gallbladder Disorders
Pain or biliary colic
Nausea, vomiting
Indigestion and flatulence
Low-grade fever
Jaundice
See Table 30-1 on p. 695.

9. Cholelithiasis and Cholecystitis
Treatment
Diet
Correction of bile obstruction
Antibiotics
Post-cholecystectomy diet
Surgery
Complications

10. 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.

11. 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.

12. Nursing Management Preoperative care Postoperative care
Caring for a T-tube

13. T-Tube
See Figure 30-2 on p. 697.

14. Hepatitis Etiology and pathophysiology Signs and symptoms
Types of viral hepatitis
HBV among Asian Americans
Signs and symptoms
Pre-icteric phase
Icteric phase
Posticteric phase
Complications

15. Comparison of Hepatitis-Causing Viruses
Transmission modes
Incubation periods
Infective periods
Signs and symptoms
See Table 30-2 on p. 698.

16. Diagnosis of Hepatitis
Serologic assays or enzyme immunoassays (EIAs)
Liver biopsy
Elevations in liver function tests (LFTs)

17. Laboratory Tests Aspartate aminotransferase (AST)
Alanine aminotransferase (ALT)
Gamma-glutamyl transpeptidase (GGT)
Bilirubin
Alkaline phosphatase
Serum albumin
Serum bilirubin (total)
Prothrombin time
See Table 30-3 on p. 700.

18. 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. 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. 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.

21. 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

22. Prevention of Hepatitis
Home considerations for different types of viral hepatitis
Standard Precautions guidelines
Infection control

23. Cirrhosis Etiology Postnecrotic cirrhosis
Laënnec’s cirrhosis or portal cirrhosis
Biliary cirrhosis
Cardiac cirrhosis
Liver-related deaths

24. 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. Signs and Symptoms Subjective symptoms Fatigue Weakness Headache
Anorexia
Indigestion
Abdominal pain
Nausea
Vomiting

26. 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

27. 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.

28. 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.

30. Signs and Symptoms of Cirrhosis
See Figure 30-3 on p. 707.
From Lewis SL, Heitkemper MM, Dirksen SR, et al: Medical-surgical nursing: assessment and management of clinical problems, ed. 9, St. Louis, 2014, Mosby.

31. Relationship of Systemic Portal Hypertension and Ascites in Cirrhosis
See Concept Map 30-1 on p. 706.

32. Nursing Management of Cirrhosis
Assessment
Assess for safety issues
Laboratory tests
Alcohol withdrawal
Nursing diagnosis
Planning and implementation
Evaluation

33. Complications of Cirrhosis
Esophageal varices
Encephalopathy
Delirium, convulsions, asterixis, and coma
Fetor hepaticus

34. Treatment for Esophageal Varices
See Figure 30-4 on p. 711.

35. Liver Transplantation
Legal and ethical considerations
Nursing management
Care of drains
Immunosuppressants
Liver function monitoring

36. Cancer of the Liver Etiology Pathophysiology Signs and symptoms
Diagnosis
Treatment
Nursing management

37. Acute Pancreatitis Etiology Pathophysiology Signs and symptoms
Diagnosis
Treatment
Nursing management

38. 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.

39. Chronic Pancreatitis (Cont.)
Treatment
Nursing management
Pain management
Complications, including diabetes mellitus
Avoid alcohol.

40. Pathophysiology of Acute Pancreatitis
See Concept Map 30-2 on p. 713.

41. Cancer of the Pancreas Etiology Pathophysiology
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

42. 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

43. 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