CHOLY, APPENDICITIS, PANCREATITIS

A 48-year-old client is being seen in her physician's office for complaints of indigestion, heartburn, right upper quadrant pain, and nausea of 4 days' duration, especially after meals. The nurse realizes that these symptoms may be associated with cholecystitis and therefore would check for which specific sign during the abdominal assessment?

A. Cullen's sign

B. Rebound tenderness

C. Murphy's sign

D. Turner's sign

Correct Answer: C

Explanation/Reference:

Explanation:

(A) This sign is a faint blue discoloration around the umbilicus found in clients who have hemorrhagic pancreatitis.

B) This sign indicates areas of inflammation within the peritoneum, such as with appendicitis.

It is a deep palpation technique used on a nontender area of the abdomen, and when the palpating hand is removed suddenly, the client experiences a sharp, stabbing pain at an area of peritoneal inflammation.

C) This sign is considered positive with acute cholecystitis when the client is unable to take a deep breath while the right upper quadrant is being deeply palpated. The client will elicit a sudden, sharp gasp, which means the gallbladder is acutely inflamed.

D) This is a sign of acute hemorrhagic pancreatitis and manifests as a green or purple discoloration in the flanks.

The nurse is caring for a client with chronic pancreatitis. Which of the following should be included in the client's teaching plan? (Select all that apply)

A. Avoid high-fat foods

B. Increase intake of protein-rich foods

C. Avoid alcohol consumption

D. Take pancreatic enzyme supplements with meals

E. Increase intake of simple carbohydrates

Correct Answers: A. Avoid high-fat foods, C. Avoid alcohol consumption, D. Take pancreatic enzyme supplements with meals

Rationale: Clients with chronic pancreatitis should avoid high-fat foods to reduce pancreatic workload, avoid alcohol to prevent further damage, and take pancreatic enzyme supplements with meals to aid digestion. Increased protein intake may be advised, but the key focus should be on enzyme supplementation and dietary modifications to manage symptoms. Simple carbohydrates should not be increased as they can exacerbate blood sugar control issues in these patients

Which client should a nurse assess first?

A. Client with pancreatitis complaining of jaw pain, 4 in scale of 10.

B. Client dependent on insulin who complains of feeling shaky and hungry.

C. Client who is confused, who has activated the bed alarm used to prevent falls.

D. Client with "red-coloured urine" drainage in Foley bag following TURP surgery

Ans: A

Jaw pain is not a typical of pain pattern for pancreatitis, therefore, the client needs to be assessed for myocardial ischaemia.

The nurse is caring for a client who has been admitted with pancreatitis. Which of the following assessment findings is consistent with this diagnosis?

1. Unreactive Cullen's sign

2. Neutropenia

3. Postitive Turner's sign

4. Weight gain

3.

Postitive Turner's sign

A client with pancreatitis may have a positive Turner's sign, which is bruising at the flank area.

Unreactive Cullen's sign

Pancreatitis can illicit a positive Cullen's sign, not an unreactive Cullen's sign.

Weight gain

Weight loss will be noted in this client, not weight gain.

Neutropenia

The client with pancreatitis will have an increase WBC count due to the inflammation and infection.

A client enters the emergency room complaining of severe and intolerable pain in the upper right quadrant of their abdomen. When asked about the pain, the client states that the onset was sudden and that it radiates to their back and right shoulder. Suspecting a diagnosis of cholelithiasis, the nurse sends the appropriate diagnostic tests and performs a focused assessment.

> Which of the following results would indicate possible cholelithiasis?

Select all that apply:

1. Temperature of 99.5 °F (37.5 °C)

  2. Elevated direct bilirubin

3. Elevated WBC count

4. Bloody and tarry stools

5. Pruritus

6. Steatorrhea

7. Intolerance of foods high in carbohydrates

8. Red urine

Cholecystitis is characterized by inflammation of the gallbladder that most commonly occurs in the presence of cholelithiasis. This is a condition where gallstones form in the gallbladder and obstruct cystic or bile ducts, which lead to bile being unable to exit the gall bladder. The build-up of bile results in irritation of the mucosa, distension, increased gall bladder pressure and inflammation.

Obstruction of ducts often produce the following symptoms:

• pain in the upper right quadrant of the abdomen

• pain that radiates to the back, right scapula or shoulder

• fever

• jaundice

• dark amber urine . clav-colored stools

• pruritus

• steatorrhea

• intolerance of fatty foods

In elevated white blood cell count

• elevated direct (conjugated) bilirubin levels

RATIONALE:

Correct answers:

(Option #2) An elevated direct bilirubin level indicates an obstruction.

(Option #3) An elevated white blood cell count indicates a sign of infection and is commonly seen in cholecystitis and associated duct obstruction.

(Option #5) Pruritus indicates the deposition of bile salts in skin tissues. This is a commonly observed symptom of a biliary tract disorder.

(Option #6) Steatorrhea (increase in fat excretion within the stool) is a symptom of fat malabsorption which can occur with biliary tract disorders.

Incorrect answers:

(Option #1) This assessment falls within the normal range. A temperature of 100.4 oF (38°C) or greater indicates a fever.

(Option #4) Bloody and tarry stools present in clients with bleeding of the gastrointestinal tract.

Obstruction of the biliary tract would produce clay-colored stools.

(Option #7) Intolerance of fatty foods is commonly seen with biliary tract disorders, not foods high in carbohydrates.

(Option #8) Red urine is not seen in biliary tract disorders and may indicate bleeding of the urinary tract. In biliary tract disorders, urine will often be dark in color due to bilirubin excreted through the kidneys.

The nurse is preparing a client with cholecystitis for discharge. The nurse is providing discharge education to the client regarding dietary changes.

Which statement made by the client indicates further education is required?

1. " will need to adhere to a low-calorie diet to promote weight loss"

2. "I will need to take supplemental fat-soluble vitamins"

3. ⁠ "A high-protein diet will help to reduce symptoms of cholecystitis"

4. ⁠ "I can be referred to the dietitian to discuss dietary modifications"

Correct Answer(s):

"I will need to adhere to a low-calorie diet to promote weight loss" - Low-calorie diets and fasting are contraindicated with cholecystitis as rapid weight loss can actually promote the formation of gallstones. To manage symptoms and promote a healthy weight loss, clients may modestly decrease calorie intake and increase their levels of activity. Clients who are obese may benefit from a reduced-calorie diet, however, there is no indication that the client in question is obese and therefore this statement by the nurse would be inappropriate.

Incorrect Answer(s):

'I will need to take supplemental fat-soluble vitamins" - Clients with gallladder diseases often have specific vitamin deficiencies, particularly of the fat-soluble vitamins (A, D, E, K).

"A high-protein diet will help to reduce symptoms of cholecystitis" - The client is advised to follow a low-fat and high-protein diet to reduce the painful episodes associated with cholecystitis, therefore this answer is

incorrect.

" can be referred to the dietitian to discuss dietary modifications" - A consultation with a dietitian can help the client create meal plans that promote recovery and management of cholecystitis.

A client with cholecystitis asks the nurse, "how goldenseal, a herb, can treat their condition?"

Which of the following is the best response by the nurse?

1. "Goldenseal can help relieve the symptoms of cholecystitis."

2. "You should consult with your health care provider (HCP) before taking goldenseal."

3. ⁠"Goldenseal does not treat cholecystitis. The herb is used for pancreatitis."

4. "Goldenseal is contraindicated for use during pregnancy and lactation"

Correct Answer(s):

"Goldenseal can help relieve the symptoms of cholecystitis." - Berberine is an active ingredient of goldenseal and studies have found it to provide relief of cholecystitis symptoms, stimulate bile secretion and reduce the growth of pathogens that commonly infect the gallbladder.

Incorrect Answer(s):

"You should consult with your health care provider (HCP) before taking goldenseal." - The nurse should first answer the client's inquiry about how the herb can help treat their cholecystitis and then proceed to let the client know to consult their HCP.

"Goldenseal is contraindicated for use during pregnancy and lactation" - Although this statement is accurate, the nurse should address how the goldenseal can treat their condition.

"Goldenseal does not treat cholecystitis. The herb is used for pancreatitis." - Goldenseal is effective in treating cholecystitis, therefore this statement is incorrect.

TAKEAWAY:

Goldenseal can be used to treat the symptoms of cholecystitis, stimulate bile secretion and reduce the growth of pathogens that commonly infect the gallbladder

A client with cholecystitis is taking propantheline bromide (Pro-Banthine). The

expected outcome of this drug is:

1. Increased bile production.

2. Decreased biliary spasm.

3. Absence of infection.

4. Relief from nausea

2. 2. Propantheline bromide is an anticholinergic used to decrease biliary spasm.

Decreasing biliary spasm helps to reduce pain in cholecystitis. Propantheline does not

increase bile production or have an antiemetic effect, and it is not effective in treating

infection.

CN: Pharmacological and parenteral therapies; CL: Apply

The nurse is monitoring a client admitted to the hospital with a diagnosis of appendicitis who is scheduled for surgery in 2 hours. The client begins to complain of increased abdominal pain and begins to vomit. On assessment, the nurse notes that the abdomen is distended and bowel sounds are diminished. Which is the most appropriate nursing intervention?

A. Notify the health care provider (HCP).

B. Administer the prescribed pain medication.

C. Call and ask the operating room team to perform surgery as soon as possible.

D. Reposition the client and apply a heating pad on the warm setting to the client's abdomen.

A. Notify the health care provider (HCP).

Rationale:

On the basis of the signs and symptoms presented in the question, the nurse should suspect peritonitis and notify the HCP. Administering pain medication is not an appropriate intervention. Heat should never be applied to the abdomen of a client with suspected appendicitis because of the risk of rupture. Scheduling surgical time is not within the scope of nursing practice, although the HCP probably would perform the surgery earlier than the prescheduled time.

The nurse is educating clients on the symptoms of appendicitis.

Individuals with appendicitis present with generalized pain that localizes to which section of the abdomen?

1. Right upper quadrant

2. ⁠ Left upper quadrant

3. ⁠ Left lower quadrant

4. ⁠Right lower quadrant

Clients with appendicitis will initially present with mild, generalized abdominal pain with low grade fever, anorexia, nausea and vomiting. As the condition progresses there is an increase in pain level and pain localizes to the right lower quadrant of the abdomen at McBurney's point with rebound tenderness. Once diagnosed, clients are usually prepared for an appendectomy to remove the inflamed appendix. In this preoperative period clients must be monitored for signs and symptoms that are suggestive of a rupture of the appendix.

RATIONALE:

Correct Answer(s):

Right lower quadrant - This answer is correct because as the condition progresses there is an increase in pain level and pain localizes to the right lower quadrant of the abdomen at McBurney's point with rebound tenderness.

Incorrect Answer(s):

Right upper quadrant - This answer is incorrect because appendicitis does not occur in the right upper quadrant

Left upper quadrant - This answer is incorrect because appendicitis does not occur in the left upper quadrant.

Left lower quadrant - This answer is incorrect because appendicitis does not occur in the left lower quadrant

Jerry has been diagnosed with appendicitis. He develops a fever, hypotension, and tachycardia. The nurse suspects which of the following complications?

A. Intestinal obstruction

B. Peritonitis

C. Bowel ischemia

D. Deficient fluid volume

Correct Answer: B. Peritonitis

Complications of acute appendicitis are peritonitis, perforation and abscess development. Diffuse peritonitis and sepsis can also develop, which may progress to significant morbidity and possible death. Postoperative abscesses, hematomas, and wound complications are all complications that can be seen after appendectomies. If the wound does get infected, one may grow Bacteroides. “Recurrent” appendicitis can occur if too much of the appendiceal stump is left after an appendectomy.

A 23-year-old male presents to the emergency department with complaints of progressively worsening abdominal pain and nausea over the past 12 hours. The nurse takes his vital signs and notes that he has a fever. The abdomen examination reveals a somewhat rigid abdomen with guarding and extreme tenderness in the right lower quadrant midway between the umbilicus and the superior iliac spine. Normal bowel sounds are present. Based on this history and presentation, which of these medical emergencies should the nurse suspect?

1.acute appendicitis

2.acute gastrointestinal bleed

3.intussusception

4.peritonitis

Correct 1

Explanation:

This patient presents with the classic history and findings of acute appendicitis. While pain may be diffuse or periumbilical early, classic appendicitis pain localizes in the right lower quadrant at McBurney’s point (midway between the umbilicus and superior iliac spine). The treatment is emergency appendectomy. Failure to treat in a timely manner may lead to rupture, peritonitis, sepsis, and death. Intussusception usually occurs in children (95% of cases) and is caused by ischemia due to invagination of a proximal part of the bowel into a section distal to it. Signs and symptoms include colicky abdominal pain, blood and mucous mixed stools (currant jelly stools), fever, and vomiting. Peritonitis is an infection and inflammation of the peritoneal cavity due to contamination from gastrointestinal products. While the signs and symptoms may be similar to appendicitis, the patient’s vitals will likely be abnormal due to shock (tachycardia, tachypnea, etc.) In addition, bowel sounds are likely to be decreased or absent. The history should also support an underlying cause (i.e., prolonged appendicitis, diverticulitis, etc.) An acute gastrointestinal bleed will likely present with signs of hypovolemic shock (abnormal vitals), and the patient may or may not be febrile and will have evidence of blood in the stool or frank hematochezia.

A child is admitted to the emergency department due to suspected ruptured appendicitis with perforation. What would be the priority nursing assessment for this client?

1. Monitor for the Rovsing sign.

2. Assess for an increase in temperature.

3. Check for rebound tenderness at McBurney's point.

4. Monitor for increasing pain and rigidity of the abdomen.

4. Correct: Increasing pain and rigid, board-like abdomen are signs that the appendix may have ruptured, with resulting peritonitis developing.

1. Incorrect: The Rovsing Sign results in RLQ pain that occurs with palpation of the LLQ. This suggests peritoneal irritation due to palpation of a remote location and would indicate appendicitis.

2. Incorrect: Although children with appendicitis may have an elevated temperature, the priority would be assessing for the signs of peritonitis which include increasing pain and rigidity of the abdomen. Children can have an increased temperature with many different types of inflammation and infections.

3. Incorrect: Although rebound tenderness at McBurney's point is indicative of appendicitis, the nurse should not check for this due to the possibility of rupturing the appendix.