Exam 4

Cholelithiasis

• Stones in the gallbladder

• Risk factors

  • Over 40

  • Obesity

  • Female

  • Multiparous

• S/S

  • Pain, depending on the severity of gallstones

  • Fullness, abdominal distention, RUQ pain

  • Biliary colic – follows a meal rich in fried or fatty foods

Cholecystitis

• Acute or chronic inflammation of the gallbladder

• Calculous cholecystitis – gallbladder stone obstructs bile outflow

• Acalculous cholecystitis – absence of gallstones

• Risk for secondary infection and perforation

• S/S – RUQ pain, may radiate to the midsternal/right shoulder, nausea, vomiting, and s/s of acute inflammation

Gallbladder disease subjective and objective assessment

• Subjective

  • Pain – Murphy’s Sign

  • Distention/fullness

  • N/V

• Objective

  • Fever

  • Jaundice/pruritic

  • Stool and urine characteristics

• Labs

  • CBC

  • PT/INR and PTT

  • Aspartate aminotransferase (AST)

  • Alanine aminotransferase (ALT)

Diagnosis of gallbladder disease

• Ultrasound (90% accuracy), X-ray

• Endoscopic retrograde cholangiopancreatography (ERCP)

  • Stone removal

ERCP Pre-procedure

• Educate patient on the procedure and their role

• NPO

• Consent

• IV

ERCP post-procedure

• Monitor patient condition, vital signs, assessing for signs of perforation or infection

• Side effects of any meds administered during the procedure (sedatives)

• Risk for pancreatitis

Gallbladder disease implementations

• Reduce the incidence of acute episodes of pain and cholecystitis by supportive and dietary management

• Remove the cause by pharmacological therapy, endoscopic procedures, and surgical intervention

• Nutrition and supportive therapies

Nutrition and supportive therapies for gallbladder disease

• 80% of patients with mild acute gallbladder inflammation achieve remission with bowel rest, IV fluids, nasogastric suction, analgesia, and antibiotics

• Surgical intervention after acute symptoms subsides

• Advancing diet: low-fat liquids

  • High protein supplements, skim milk, cooked fruits, rice/tapioca, lean meats, non-gas forming vegetables, bread, coffee, or tea

• Avoid eggs, cream, pork, fried foods, cheese, rich dressings, gas-forming vegetables, and alcohol

• Fatty foods may exacerbate episodes

Pharmacological interventions for gallbladder disease

• Analgesics

• Anti-emetics

• IV fluids

• Ursodeoxycholic acid (UDCA) or Chenodeoxycholic acid (chenodiol or CDCA) PO

• Mono-octanoin or methyl tertiary butyl ether

• Lithotripsy

• Surgery

Ursodeoxycholic acid (UDCA) or Chenodeoxycholic acid (chenodiol or CDCA) PO

• Medication used to treat gallbladder disease

• Reduces the size or dissolves small gallstones (cholesterol stones)

• Prevents more gallstones from occurring

• 6-12 months of therapy required

• Not eligible for patients with frequent symptoms, cystic duct occlusion, or pigment stones

• Used if surgery is contraindicated or refused

Mono-octanoin or methyl tertiary butyl ether

• Medication used to treat gallbladder disease

• Infused through a percutaneous tube directly into the gallbladder or via ERCP

• Used to dissolve gallstones

Lithotripsy

Laser pulse or shock wave therapy causing gallbladder stones to fragment

Laparoscopic cholecystectomy

• Surgical procedure to treat gallbladder disease

• Carbon dioxide to inflate abdomen

• Fiberoptic scope with camera

• Removed through abdomen incision

• May require a Jackson-Pratt drain

• Monitor for peritonitis, infection, bile duct injury, or bleeding

Laparoscopic cholecystectomy post-op care

• Airway

• Breathing (CDB/IS)

• Circulation (VS, DVT)

• Pain

• Nausea/vomiting

• Bowel sounds

• Incision/drain care

• Activity

• Low-fat diet

Gallbladder disease surgical implementations

• Laparoscopic cholecystectomy

• Open cholecystectomy

• Transhepatic biliary catheter

Acute pancreatitis

• 80% caused by cholelithiasis or alcohol abuse

• Mild – interstitial (edematous) pancreatitis

• Severe – necrotizing pancreatitis

• Pathology – autodigestion of the pancreas

Subjective assessment of acute pancreatitis

• Alcohol use

• Pain: mid-epigastrium, back

• N/V

• PMH

Objective assessment of acute pancreatitis

• Integumentary

• Respiratory

• GI/GU

• VS

• CBC, BMP

  • Hypocalcemia, hyperglycemia

• Amylase/lipase

• Ultrasound

• CT

CT for acute pancreatitis

• Check creatine

• Teach about warm feeling

• Screen for allergies

• Contrast? Start IV

• Assess for reactions

• NPO if ordered

Pain implementations for acute pancreatitis

• Parenteral opioids

• PCA

• Antibiotics

• PPI

• NG to LIS

• Non-pharmacological

• Biliary drains and stents

• Bed rest

Imbalance nutrition implementations for acute pancreatitis

• NPO

• TPN

• Anti-emetics

• Electrolyte replacement – Calcium

• Eliminate alcohol/caffeine

• Albumin levels

• Daily weights

• Accu checks/insulin administration

• Pancrelipase pancreatic enzyme

  • Creon

  • Pancreatic enzyme

Deficient fluid volume implementations for acute pancreatitis

• IV fluids

• Blood products as needed

• Anti-emetics

• Daily weights

• Albumin infusion

Risk for impaired gas exchange implementations for acute pancreatitis

• Positioning – Semi-Fowler’s

• C&DB

• IS

• ABGs

• Oxygen as needed

Pancreatic cancer risk factors and diagnosis

• RF: smoking, alcohol, diets high in fats/meats, obesity, chemicals/toxins

• Metastasis likely due to malignant cells shedding into the peritoneal cavity (lung and liver)

• Diagnosis: spiral CT, ERCP with fine-needle biopsy

• Usually don’t seek medical attention until later stages

Pancreatic cancer surgical treatment

• Pancreatoduodenectomy (Whipple procedure)

• Total pancreatectomy)

• Nursing care before and after

  • Nutritional needs

  • Pain control

  • Infection/bleeding precautions

  • Blood glucose control

  • Vital signs

Causes of liver failure

• Viral hepatitis

• Drugs and chemicals: Acetaminophen, antidepressants, anticonvulsants, antifungals

• Autoimmune

• Wilson’s disease – inherited disease; excessive amount of copper

• Hemochromatosis – iron overload

• Nonalcoholic fatty liver disease

Diagnosis of hepatic disorders

• AST, ALT, GGT

• Look for underlying cause

  • Virology testing

  • Biopsy

    • Informed consent

    • Post-procedure

      • Right-side lying

      • Monitor VS and for complications

• Ultrasound

Clinical manifestations of hepatic disorders

• Integumentary – jaundice, pruritus, spider angioma, petechiae

• Endocrine – inability to metabolize hormones (estrogen and testosterone)

• Hematologic – anemia, thrombocytopenia, coagulation disorders, splenomegaly

• Metabolic – electrolyte imbalances (hypokalemia, hyponatremia, hypoalbuminemia)

• Cardiovascular – fluid retention, peripheral edema, ascites

• GI – changes in bowel, N/V, esophageal/gastric varices, hemorrhoidal varices

• Neurological – hepatic encephalopathy, asterixis

• Portal HTN

• Ascites

Subjective data for hepatic disorders

• PMH – family history

• Medications – prescribed and OTC, herbal

• Pain and weakness

Objective data for hepatic disorders

• Vitals

• Bleeding – easy bruising, hypotension, blood in emesis or stool

• CV – edema

• Integumentary – jaundice, ecchymoses, pallor

• MSK – atrophy

• Respiratory – hypoxia

• GI/GU – ascites, palpable liver and spleen

• Neurological – AMS, asterixis, hepatic encephalopathy

Labs for hepatic disorders

• CBC/BMP

• Albumin

• Ammonia

• Bilirubin

• Platelet

• PT/INR

• LFTs

PT/INR

• Prothrombin time/INR: measures the body’s ability to clot

• Elevated INR = risk of bleeding: Vitamin K → increases coagulation

Implementations for imbalanced nutrition in hepatic disorders

• High-CHO, protein, and calorie diet (UNLESS ammonia levels are high*) – may need to do enteral feeding

• Low sodium (500-2000 mg/day)

• Vitamin supplements (A, D, E, K)

Implementations for skin integrity in hepatic disorders

• Lotions

• Medications

  • Pruritus: hydroxyzine (PO) – antihistamine

• Meticulous skin care

  • Edematous areas are more prone to breakdown

  • Specialty mattress

  • Turning schedule

  • Mobility

Implementations for excess fluid in hepatic disorders

• Fluid and sodium restriction

• Diuretics

• Ascites

• Paracentesis

• Transjugular intrahepatic portosystemic shunt (TIPS)

• Positioning

• Electrolyte replacement

• Albumin – can be given through an IV

Paracentesis

• Procedure to treat ascites

• Informed consent

• Empty bladder to avoid bladder puncture

• Obtain fluid samples for culture

• Aseptic technique

• Assist with positioning during procedure

Implementations for esophageal or gastric varices

• IV fluids – aggressive fluid resuscitation; place a large-bore IV

• Blood transfusion

• CBC, BMP, clotting factors

• Foley catheter (strict I&Os)

• Balloon tamponade

• Endoscopic sclerotherapy/variceal ligation banding

• TIPS procedure

• Beta-blockers – used to prevent first episode of bleeding

TIPS procedure

creates a pathway between the portal vein and hepatic vein in the liver to reduce portal HTN and swelling