Liver: Assessment and Management of Patients with Hepatic Disorders

Liver: Anatomy and Physiology

• Largest gland of the body

• Located in the upper right abdomen

• A very vascular organ that receives blood from GI tract via the portal vein and from the hepatic artery

Metabolic Functions of the Liver

• Glucose metabolism

• Ammonia conversion

• Protein metabolism

• Fat metabolism

• Vitamin and iron storage

• Bile formation

• Bilirubin excretion

• Drug metabolism

Health History

• Previous exposure to hepatotoxic substances or infectious agents

• Travel, alcohol and drug use

• Lifestyle

Physical Assessment

• Skin

  • jaundice - yellow skin

• Cognitive status

  • confusion

• Palpation, Percussion

  • Shouldn’t feel the liver easily – liver too big

  • Liver – dullness

  • Lung tissue – resonance

Liver Function Studies

• Serum aminotransferase: AST, ALT, GGT, GGTP, LDH

• Serum protein studies

• Direct and indirect serum bilirubin, urine bilirubin, and urine bilirubin and urobilinogen

• Clotting factors

• Serum alkaline phosphatase

• Serum ammonia

• Lipids

Serum aminotransferases:

indicators of injury to the liver cells; useful in detecting hepatitis

Alanine aminotransferase (ALT):

levels increase primarily in liver disorders; used to monitor the course of hepatitis, cirrhosis, the effects of treatments that may be toxic to the liver

Aspartate aminotransferase (AST):

not specific to liver diseases; however, levels of AST may be increased in cirrhosis, hepatitis, and liver cancer

Gamma-glutamyl transferase (GGT):

levels are associated with cholestasis; alcoholic liver disease

common hepatotoxic drugs

• Amoxicillin-clavulanate (Augmentin)

• Acetaminophen (Tylenol)

• Antibiotics

  • Isoniazid (anti-tuberculosis), Nitrofurantoin, Trimethoprim-sulfamethoxazole (Bactrim), Azithromycin and Ciprofloxacin

• Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)

  • Diclofenac, Ibuprofen

• Cardiovascular Medications & Statins:

  • Atorvastatin, Simvastatin, and Fluvastatin, Amiodarone

• Immunosuppressants & Biologics

  • Azathioprine, Infliximab, Methotrexate

• Anticonvulsants / Anti-seizure Drugs:

  • Valproic acid, Phenytoin

Diagnostic Studies

• Liver Biopsy

  • A needle is inserted through the skin, often between the ribs, to obtain a small tissue sample from the liver.'

  • Complications

    • Bleeding — major complication because the liver has a rich blood supply.

    • Infection.

    • Leakage from the biopsy site.

  • Nursing Care

    • Position: Place the patient on the right side after the biopsy to apply pressure to the biopsy site and help reduce bleeding, as ordered.

    • Monitor vital signs: Watch for hypotension, tachycardia, and other signs of bleeding.

    • Monitor the biopsy site: Check for bleeding or fluid leakage.

    • Assess for abdominal pain, increasing abdominal distention, dizziness, or weakness.

• U/S

• CT

• MRI

MRI Safety

• Screen for metal: Check for pacemakers, implants, aneurysm clips, metal fragments, and other MRI-incompatible devices.

• Remove metal objects: Jewelry, watches, hairpins, hearing aids, and other metal items.

• Assess for claustrophobia: Explain the procedure; provide prescribed sedation if needed.

• Check allergies and kidney function if contrast (gadolinium) is ordered, following facility protocol.

• Explain the procedure: The patient must lie still; the machine makes loud noises, so earplugs or headphones may be provided.

• Assess pregnancy status when relevant and follow facility screening protocols.

• Monitor the patient during and after the procedure, especially if sedation or contrast is used.

Hepatic Dysfunction

• Acute or chronic, cirrhosis of the liver

• Liver failure associated with alcohol use

• Infection

• Fatty liver disease

  • Nonalcoholic fatty liver disease (NAFLD)

  • Nonalcoholic steatohepatitis (NASH)

• Jaundice

• Portal Hypertension

• Ascites and Varices

• Hepatic Encephalopathy or Coma

• Nutritional Deficiencies

Jaundice

• Yellow or greenish-yellow discoloration of the skin and sclera caused by increased serum bilirubin.

• Bilirubin level: Jaundice typically becomes noticeable when bilirubin exceeds approximately 2 mg/dL.

  • Normal: 0.3–1.0 mg/dL

Types of Jaundice

Type	Cause
Hemolytic (prehepatic)	Excessive breakdown of red blood cells produces too much bilirubin.
Hepatocellular (hepatic)	Liver cell damage prevents the liver from properly processing bilirubin.
Obstructive (posthepatic)	Blockage of bile flow prevents bilirubin from being excreted normally.
Hereditary hyperbilirubinemia	Genetic conditions affect bilirubin processing or excretion.

• Hepatocellular and obstructive jaundice are most associated with liver disease

Bilirubinuria

• Presence of bilirubin in the urine

• Urine may appear dark brown, tea-colored, or amber.

Jaundice - Skin Assessment

• Inspect the sclera: Look for yellow discoloration (scleral icterus).

• Assess for itching (pruritus): Bilirubin-related liver or bile flow problems can cause itching due to the buildup of bile components in the skin.

• Inspect the skin: Look for jaundice, excoriations (scratch marks), redness, or skin breakdown caused by scratching.

• Monitor skin integrity: Keep the skin clean and moisturized, keep nails short, and help prevent scratching-related injury.

Hepatocellular Jaundice

• Caused by liver cell damage

• Patient may be mildly or severely ill

• Loss of appetite

• Nausea and vomiting

• Weight loss

• Malaise, fatigue, and weakness

• Headache, chills, and fever may occur

Obstructive Jaundice

• Caused by blockage of bile flow

• Bile cannot flow normally into the intestine

• Dark orange-brown urine

• Clay-colored or pale stools

• Dyspepsia (indigestion)

• Intolerance of fatty foods due to impaired fat digestion

• Pruritus (itching)

Portal Hypertension

• Obstructed blood flow through the liver results in increased pressure throughout the portal venous system

Results in:

• Ascites: Accumulation of fluid in the abdominal cavity.

• Esophageal varices: Enlarged veins in the esophagus that can rupture and cause severe bleeding.

Assessment of Ascites

• Measure abdominal girth daily to monitor fluid accumulation.

• Weigh the patient daily at the same time, using the same scale and similar clothing and bedding.

• Inspect the abdomen for:

  • Striae (stretch marks).

  • Distended abdominal veins.

  • Umbilical hernia.

• Assess for fluid in the abdominal cavity:

  • Shifting dullness: Percuss the abdomen and assess for changes in sound as the patient changes position.

  • Fluid wave: Assess for transmission of a wave of fluid across the abdomen.

• Monitor fluid and electrolyte balance, including intake and output.

• Assess respiratory status: Severe ascites can push the diaphragm upward, making breathing difficult, especially when lying flat.

• Understand fluid distribution: Ascitic fluid shifts toward the dependent (lowest) areas of the abdomen when the patient's position changes.

Treatment of Ascites

• Low-sodium diet

  • Reduces fluid retention.

  • Avoid high-sodium foods: ramen, canned foods, processed foods, and salty fried foods.

  • Choose fruits, vegetables, lean meats, and beans without added salt.

• Diuretics

  • Help remove excess fluid from the body.

  • Monitor potassium (K⁺), electrolytes, intake and output (I&O), daily weight, and edema.

  • Give in the morning when possible to reduce nighttime urination.

• Bed rest

  • May be prescribed in selected cases.

• Paracentesis

  • Uses a needle or catheter to remove excess fluid from the abdominal cavity.

  • Monitor vital signs, bleeding, and fluid leakage.

• Salt-poor albumin

  • Helps draw and retain fluid in the bloodstream through oncotic pressure.

  • May be given after large-volume paracentesis to help maintain circulating blood volume.

• Transjugular intrahepatic portosystemic shunt (TIPS)

  • Creates a pathway between blood vessels in the liver to reduce portal hypertension.

  • May be used for ascites that does not respond to standard treatment.

Paracentesis

• Removes excess fluid from the abdominal cavity (ascites) to relieve abdominal pressure and improve breathing.

• Complications:

  • Bleeding: Patients with liver disease may have impaired blood clotting.

  • Infection: Monitor for signs of infection.

  • Hypotension: Can occur after fluid removal.

• Respiratory assessment:

  • Ascites can press against the diaphragm and make breathing difficult.

  • Monitor respiratory status before and after the procedure.

• Puncture site care:

  • Monitor for bleeding and fluid leakage.

  • An ostomy bag or drainage pouch may be placed over the site to collect leaking fluid.

• Monitor vital signs, especially blood pressure, during and after the procedure.

• Position: Place the patient in Fowler’s position (sitting upright) or a high-Fowler’s position during paracentesis.

  • Helps fluid collect in the lower abdomen and allows the patient to breathe more easily.

Nursing Considerations for Ascites

• Diuretics: Monitor potassium, electrolytes, blood pressure, and urine output.

• Bed rest: Follow prescribed activity and rest recommendations.

• Paracentesis: Monitor vital signs, especially blood pressure, and assess for bleeding, infection, and fluid leakage.

• Transjugular intrahepatic portosystemic shunt (TIPS): Monitor for complications and signs of hepatic encephalopathy.

• Aldactone (spironolactone): Potassium-sparing diuretic; monitor potassium levels and blood pressure.

• Low-sodium intake: Restrict sodium as prescribed to reduce fluid retention.

• Intake and output (I&O): Monitor fluid balance.

• Daily weights: Weigh at the same time each day using the same scale and similar clothing.

• Abdominal girth: Measure daily at the same location to monitor fluid accumulation.

• Patient/family education: Teach sodium restriction, medication adherence, daily weights, and when to report worsening abdominal swelling, shortness of breath, fever, or dizziness.

Encephalopathy and Coma

Life-threatening complications of liver disease caused by the buildup of ammonia and other toxic substances in the blood, which affect brain function.

Encephalopathy and Coma - Two major causes:

• Hepatic insufficiency: The liver cannot properly detoxify toxic waste products from metabolism.

• Portosystemic shunting: Blood from the portal system bypasses the liver, allowing toxins to enter the systemic circulation and reach the brain.

Encephalopathy and Coma - Early Signs

• Mental changes: Confusion, personality changes, difficulty concentrating, and altered level of consciousness.

• Motor disturbances: Tremors, poor coordination, and asterixis (flapping tremor of the hands).

Esophageal Varices

• Enlarged, swollen veins in the esophagus caused by portal hypertension. These veins can rupture and cause life-threatening bleeding.

• Ruptured varices can cause massive bleeding and death.

• Mortality can be 40%

Esophageal Varices - Manifestations:

• Hematemesis: Vomiting blood.

• Melena: Black, tarry stools caused by digested blood.

  • Upper GI bleeding: May cause hematemesis and black, tarry stools because blood is digested as it passes through the GI tract.

  • Lower GI bleeding: Often causes bright red or maroon blood in the stool, depending on the bleeding site and rate.

• General deterioration: Weakness and worsening condition.

• Shock: May occur due to severe blood loss.

Esophageal Varices - Screening

Patients with cirrhosis should undergo screening endoscopy every 2 to 3 years

Esophageal Varices - Treatment

• Treat for shock

  • Administer oxygen.

  • Mechanical ventilation may be needed if the patient cannot maintain their airway or breathing.

• IV fluids, electrolytes, volume expanders, and blood products

  • Replace lost fluid and blood.

  • Help maintain circulating blood volume and blood pressure.

  • Volume expanders

    • Help replace lost fluid and maintain circulating blood volume.

    • Examples: IV crystalloids and blood products, depending on the patient's needs.

• Balloon tamponade

  • A balloon tube is inserted and inflated to compress bleeding esophageal varices.

  • Used as a temporary measure for uncontrolled bleeding while definitive treatment is arranged.

• Endoscopic band ligation

  • Bands are placed around the varices to stop bleeding.

  • Commonly used as definitive treatment for acute variceal bleeding.

Esophageal Varices - Medication

• Vasopressin, somatostatin, and octreotide

  • Help reduce blood flow to the portal system and control bleeding.

  • Vasopressin: Causes vasoconstriction but may cause chest pain due to coronary vasoconstriction.

  • Nitroglycerin: May be given with vasopressin to reduce coronary vasoconstriction.

  • Octreotide is commonly used for acute variceal bleeding.

• Beta-blockers (propranolol and nadolol)

  • Decrease heart rate and portal pressure, helping prevent future variceal bleeding.

  • Monitor blood pressure and heart rate for hypotension and bradycardia.

  • Primarily used for prevention, not as the main treatment for active bleeding.

  • Nonselective beta-blockers that reduce portal pressure.

Blood Transfusion: Nursing Steps

1. Verify the order for the blood transfusion.

2. Verify informed consent is signed.

3. Identify the patient using two identifiers, such as name and date of birth.

4. Check baseline vital signs before starting the transfusion.

5. Assess the IV line to ensure it is patent and functioning.

6. Verify the blood product with another RN according to hospital policy. Check the patient's ID band, blood type, compatibility, expiration date, and blood unit number.

7. Prepare the blood tubing with 0.9% normal saline (NS).

8. Start the transfusion slowly and remain with the patient for the first 15 minutes.

9. Recheck vital signs after 15 minutes and monitor for a transfusion reaction.

10. Continue monitoring vital signs according to hospital policy.

11. Complete the blood unit within 4 hours of starting the transfusion.

12. Monitor for fluid overload, especially when multiple units are administered.

If a Transfusion Reaction Occurs

1. Stop the transfusion immediately.

2. Disconnect the blood tubing from the patient and maintain IV access with new tubing and NS according to facility protocol.

3. Assess airway, breathing, circulation, and vital signs.

4. Notify the provider and blood bank; activate rapid response if indicated.

5. Follow the transfusion-reaction protocol, including required blood/urine samples and returning the blood bag and tubing.

Signs of a transfusion reaction

• Fever or chills

• Itching or hives

• Flushing

• Shortness of breath

• Chest or back pain

• Hypotension or other sudden vital-sign changes

Multiple-unit transfusions

• Monitor for TACO (transfusion-associated circulatory overload), especially with multiple units.

• Watch for shortness of breath, crackles, edema, and increased blood pressure.

• Administer blood products and additional fluids only as prescribed.

Treatment of Bleeding Esophageal Varices

• Endoscopic sclerotherapy

  • Injects a medication into or around the varices to cause them to shrink and stop bleeding.

• Endoscopic variceal ligation (esophageal banding therapy)

  • Places small bands around the varices to stop bleeding.

  • Commonly used to treat acute bleeding.

• Transjugular intrahepatic portosystemic shunt (TIPS)

  • Creates a channel within the liver to reduce portal hypertension.

  • May be used when bleeding is uncontrolled or recurrent.

• Surgical management

  • Surgical bypass procedures: Redirect blood flow to reduce portal pressure.

  • Devascularization and transection: Disconnects or divides vessels and tissue associated with the varices to control bleeding.

Nursing Management of Esophageal Varices

• Maintain safe environment; prevent injury, bleeding and infection

• Administer prescribed treatments and monitor for potential complications

• Encourage deep breathing and position changes

• Education and support of patient and family

Hepatic Encephalopathy

Buildup of ammonia and other toxins in the blood due to impaired liver function, affecting brain function.

Hepatic Encephalopathy - Assessment

• Stages I–IV: Progresses from mild confusion and personality changes to severe confusion, stupor, and coma.

• EEG (electroencephalogram): Records electrical activity in the brain; may show changes associated with encephalopathy.

• Changes in level of consciousness (LOC): Monitor for confusion, drowsiness, and decreased responsiveness.

• Potential seizures: Monitor for seizure activity.

• Fetor hepaticus: Distinctive musty, sweet, or sulfur-like breath odor associated with severe liver dysfunction.

• Monitor fluid, electrolyte, and ammonia levels

  
  

Stages of Hepatic Encephalopathy

Management of Hepatic Encephalopathy

• Eliminate precipitating cause

  • Identify and treat triggers such as infection, GI bleeding, constipation, dehydration, or medication effects.

  • Acetaminophen (Tylenol): Taking too much can cause severe liver damage and death. Follow the recommended dose and avoid duplicate products containing acetaminophen.

• Lactulose to reduce serum ammonia levels

  • Lowers serum ammonia by trapping ammonia in the intestines and helping remove it through stool.

  • The goal is usually 2–3 soft bowel movements per day, not severe diarrhea.

  • Monitor bowel movements, hydration, and electrolytes.

• IV glucose to minimize protein catabolism

• Protein restriction

• Reduction of ammonia from GI tract by gastric suction, enemas, oral antibiotics

  • Enemas

    • Position the patient on the left side.

    • Use the prescribed solution at the correct temperature; avoid solutions that are too hot or cold.

    • Administer slowly, monitor comfort and cramping, and encourage the patient to retain the solution as tolerated.

• Discontinue sedatives, analgesics, and tranquilizers

  • can worsen drowsiness and altered LOC

• Monitor or treat complications and infections

Hepatitis A–E Comparison Table

Category	A	B	C	D	E
Transmission	Fecal–oral; contaminated food/water	Blood, saliva, semen, vaginal secretions; sexual contact; needles; birth	Primarily blood; sharing needles; needlestick injuries	Blood and body fluids; requires HBV infection	Fecal–oral; contaminated food/water
Symptoms	Nausea, vomiting, diarrhea, anorexia, low-grade fever, malaise, jaundice	Nausea, vomiting, fever, abdominal pain, weakness, dark urine, clay-colored stools	Often asymptomatic; may have fatigue or flu-like symptoms	Similar to HBV; nausea, fever, malaise, abdominal pain, jaundice	Nausea, fatigue, jaundice; may have abdominal pain
Prevention	Hand hygiene, safe food preparation, vaccine	Vaccine, safe sex, avoid sharing needles and personal items contaminated with blood	Avoid sharing needles; safe injection practices; no vaccine	HBV vaccine prevents HDV	Hand hygiene, safe drinking water, thoroughly cooked meat
Treatment	Supportive care, hydration, symptom management	Antivirals for chronic infection; supportive care for most acute cases	Direct-acting antivirals can cure most infections	Specialist management; interferon alfa in selected cases	Supportive care; monitor for severe disease, especially during pregnancy

Hepatitis

• A and E = fecal–oral transmission.

• B, C, and D = primarily blood/body-fluid transmission.

• D requires hepatitis B infection.

• Vaccines: A and B; B vaccination also prevents D.

• Hepatitis C: No vaccine, but it is often curable with antiviral treatment.

Hepatic Cirrhosis - Pathophysiology

• Chronic liver damage causes fibrosis (scar tissue) and changes in normal liver structure.

• Scar tissue interferes with blood flow through the liver, causing portal hypertension.

• The liver becomes less able to perform its functions, including detoxification, protein production, and bile processing.

Hepatic Cirrhosis - Alcoholic cirrhosis:

Scar tissue characteristically surrounds the portal areas.

Hepatic Cirrhosis - Postnecrotic cirrhosis:

Broad bands of scar tissue form after liver cell injury.

Hepatic Cirrhosis - Biliary cirrhosis

Scarring occurs around the bile ducts.

Hepatic Cirrhosis - Manifestations

• Liver enlargement (hepatomegaly).

• Portal hypertension and obstructed blood flow through the liver.

• Ascites: Fluid accumulation in the abdominal cavity.

• Infection and peritonitis: Risk increases with ascites.

• Esophageal and gastrointestinal varices: Enlarged veins that can rupture and bleed.

• Edema: Fluid accumulation in tissues.

• Vitamin deficiencies: Due to impaired nutrient processing and absorption.

• Anemia: May result from bleeding, nutritional deficiencies, or other complications.

• Mental deterioration: Hepatic encephalopathy caused by the buildup of toxins such as ammonia.

Problems and Complications of Cirrhosis

• Bleeding and Hemorrhage

  • Cirrhosis decreases production of clotting factors, increasing bleeding risk.

  • Bleeding precautions:

    • Minimize needle sticks and invasive procedures.

    • Use central venous access with multiple lumens when indicated to reduce repeated sticks.

    • Avoid removing scabs; apply pressure after blood draws or injections.

    • Prevent injuries and falls.

    • Pad side rails if needed to prevent injury.

    • Monitor for bleeding, bruising, hematemesis, and black, tarry stools (melena).

• Hepatic Encephalopathy

  • Toxins, especially ammonia, build up because the liver cannot adequately remove them.

  • Signs: confusion, personality changes, decreased level of consciousness, and asterixis (hand-flapping tremor).

  • Nursing care: monitor neurological status, administer lactulose as prescribed, monitor stool frequency and electrolytes, and implement fall and aspiration precautions.

• Fluid Volume Excess

  • Portal hypertension and decreased albumin production contribute to fluid accumulation.

  • Manifestations: ascites, peripheral edema, weight gain, and abdominal distention.

  • Nursing care:

    • Monitor daily weight, abdominal girth, intake and output, and electrolytes.

    • Restrict sodium as prescribed.

    • Administer diuretics as prescribed and monitor potassium.

    • Monitor respiratory status because severe ascites can impair breathing.

    • Prepare for paracentesis if indicated.

S/S of Cirrhosis

Nursing Interventions for Cirrhosis - Promoting rest

• Rest and supportive measures

• Positioning for respiratory efficiency

• Oxygen

• Planned mild exercise and rest periods

• Address nutritional status to improve strength

• Measures to prevent hazards of immobility

Nursing Interventions for Cirrhosis - Improving nutritional status

• I&O

• Encourage small frequent meals

• High-calorie diet, sodium restriction

• Protein modified or restricted if patient is at risk for encephalopathy

• Supplemental vitamins, minerals, B complex, provide water-soluble forms of fat-soluble vitamins if patient has steatorrhea

• Consider patient preferences

Nursing Interventions for Cirrhosis

• Providing skin care

  • Frequent position changes

  • Gentle skin care

  • Reduce scratching related to pruritus

• Reducing risk for injury

  • Prevent falls, trauma related to risk for bleeding

Cirrhosis Treatment

• Liver transplant

  • May be needed for end-stage liver disease when the liver is severely damaged and no longer functions adequately.

• Partial liver removal (hepatectomy)

  • Removes part of the liver.

Nursing Care of the Patient Undergoing a Liver Transplantation

• Preoperative nursing interventions:

  • Support, education, and encouragement are provided to help prepare psychologically for the surgery

• Postoperative nursing interventions:

  • Monitor for infection, vascular complications, respiratory and liver dysfunction, constant close monitoring

• Caregiver stress

Patient Education for Liver Transplant

• Education about long-term measures to promote health

• Adhere closely to the therapeutic regimen, with special emphasis on administration, rationale, and side effects of immunosuppressive agents

• Education about the signs and symptoms that indicate problems necessitating consultation with the transplant team

• Emphasize the importance of follow-up laboratory tests and appointments with the transplant team

Nutrition After Liver Transplant

• Eating at least five servings of fruits and vegetables each day

• Eating lean meats, poultry and fish

• Eating whole-grain breads and cereals and other grains

• Having enough fiber in your daily diet

• Drinking low-fat milk or eating other low-fat dairy products, to help maintain enough calcium

• Maintaining a low-salt and low-fat diet

• Following food safety guidelines

• Avoiding alcohol

• Staying hydrated by drinking adequate water and other fluids each day

• Avoiding grapefruit and grapefruit juice due to its effect on a group of immunosuppression medications

Cholelithiasis (Gallstones)

• Gallstones (calculi) present in the gallbladder.

• Size, shape, and composition: Gallstones vary in size, shape, and composition.

• Composition: Most gallstones are made primarily of cholesterol; others contain bilirubin pigments.

• Risk factors: More common in women than men.

• Types:

  • Acute: Sudden symptoms, often when a stone obstructs bile flow.

  • Chronic: Repeated episodes of inflammation and irritation.

Cholelithiasis - S/S

• Right upper quadrant (RUQ) abdominal pain, often after a fatty meal.

• Nausea and vomiting.

• Inflammation and fever may indicate acute cholecystitis (inflammation of the gallbladder), often caused by a gallstone blocking the cystic duct.

• Jaundice

Charcot’s triad:

The three classic signs of ascending cholangitis:

1. Fever

2. Jaundice

3. Right upper quadrant (RUQ) pain

Acute cholecystitis

Inflammation of the gallbladder, usually caused by a gallstone obstructing the cystic duct.

Choledocholithiasis

Gallstones in the common bile duct. These can obstruct bile flow and cause jaundice.

Ascending cholangitis

Infection of the bile ducts, often caused by bile duct obstruction. Charcot’s triad is a key sign.

Cholelithiasis (Gallstones)

Cholelithiasis (Gallstones) - Pain

• Biliary colic: Pain caused by temporary obstruction of the cystic duct or common bile duct by a gallstone.

• Pain may be intermittent or steady.

• Location: RUQ, possibly radiating to the mid-upper back or right shoulder.

• Murphy’s sign: Pain that causes the patient to stop inhaling during deep inspiration while the RUQ is palpated; suggests acute cholecystitis.

• Rebound tenderness: Pain when pressure is quickly released, which may indicate peritoneal irritation.

• Abdominal guarding: Tensing of abdominal muscles due to pain or inflammation.

• Pain may occur after eating a large, high-fat meal.

Cholelithiasis (Gallstones) - Fever

Associated with the inflammatory process and/or bacterial infection

Cholelithiasis (Gallstones) - Leukocytosis

Elevated WBC count due to inflammation and/or infection.

Cholelithiasis (Gallstones) - Gastrointestinal Symptoms

• Nausea and vomiting.

• Anorexia (loss of appetite).

• Intolerance to fatty foods; some patients report intolerance to cabbage or other gas-producing foods.

• Dyspepsia (indigestion) and belching.

• Flatulence (excess gas).

Cholelithiasis (Gallstones) - Jaundice

• Yellowing of the skin and sclera due to elevated bilirubin.

• May be intermittent when a stone temporarily obstructs the common bile duct.

Cholelithiasis (Gallstones) - Treatment

• Pain management: Analgesics as prescribed.

• Diet: Avoid high-fat foods that trigger symptoms.

• Antibiotics: If bacterial infection is suspected or confirmed; not routinely needed for uncomplicated biliary colic.

• Cholecystectomy: Surgical removal of the gallbladder; common definitive treatment for symptomatic gallstones.

• ERCP: May be used to remove stones from the common bile duct.

• Monitor: Temperature, WBC count, pain, jaundice, and signs of worsening infection or obstruction.

Cholelithiasis - Chronic Symptoms:

• Jaundice: Yellowing of the skin and sclera due to increased bilirubin, often from bile duct obstruction.

• Clay-colored or pale stools: Bile cannot reach the intestines normally, reducing stool pigmentation.

• Dark or tea-colored urine: Conjugated bilirubin enters the urine when bile flow is obstructed.

• Pruritus (itching): Caused by the accumulation of bile-related substances in the skin.

• Steatorrhea (fatty stools): Results from fat malabsorption when insufficient bile reaches the intestines.

  • Pale, bulky, foul-smelling stools.

  • Stools may float and be difficult to flush.

  • Oil droplets may be visible in the toilet after a bowel movement.

Cholelithiasis - Nursing Implications

• Controlling Pain

  • Administer pain medications as prescribed.

  • Use an abdominal binder if prescribed and appropriate for comfort.

• Improving Respiratory Status

  • Encourage TC&DB (turn, cough, and deep breathe).

  • Encourage use of an incentive spirometer (IS).

  • Assist the patient out of bed (OOB) and encourage early ambulation as tolerated.

• Maintaining Skin Integrity

  • Bile salts can contribute to itching and skin irritation.

  • Assess for pruritus, scratching, and skin breakdown.

  • Keep skin clean and moisturized; use prescribed treatments for itching.

• Promoting Biliary Drainage

  • Monitor intake and output (I&O).

  • Monitor urine and stool color, jaundice, and drainage if a biliary drain is present.

  • Report signs of obstruction or infection.

• Improving Nutritional Status

  • Encourage a low-fat diet to reduce symptoms triggered by fatty foods.

  • Provide adequate carbohydrates and protein as tolerated.

• Preventing Complications

  • Report fever, worsening RUQ pain, jaundice, persistent vomiting, or changes in mental status.

  • Monitor for infection, bile duct obstruction, and pancreatitis.

• Promoting Mobility

  • Assist the patient to a chair as soon as safely possible after surgery, according to orders and tolerance.

  • Early ambulation helps reduce complications such as atelectasis and venous thromboembolism.

Acute Pancreatitis

Sudden inflammation of the pancreas caused by premature activation of digestive enzymes, resulting in pancreatic tissue damage.

Acute Pancreatitis - Causes

• Gallstones — can obstruct pancreatic drainage.

• Alcohol use — a common cause.

• Other causes include high triglycerides, certain medications, and abdominal trauma.

Acute Pancreatitis - Signs and Symptoms

• Severe abdominal pain: Often in the epigastric area (upper middle abdomen), may radiate to the back.

• Onset: May develop after a heavy meal or alcohol use; symptoms can begin within hours.

• Pain not relieved by antacids: Because the pain is caused by pancreatic inflammation, not excess stomach acid.

• Abdominal distention: Due to inflammation and decreased intestinal motility.

• Board-like abdomen: A rigid abdomen may indicate severe inflammation or peritonitis and requires urgent evaluation.

• Bruising around the umbilicus (Cullen’s sign): May indicate severe hemorrhagic pancreatitis.

• Palpable abdominal mass: May occur with a pancreatic fluid collection or pseudocyst.

• Decreased peristalsis: Reduced bowel sounds or ileus may occur.

• Nausea and vomiting.

Common: Severe epigastric pain radiating to the back, with nausea and vomiting

Acute Pancreatitis — Nursing Implications

• Liberal use of analgesics

  • PCA

  • MS04

  • Hydromorphone

  • Fentanyl 

  • Distractions 

• Improve Breathing

  • Semi-Fowler

  • O2 Sats; ABGs

  • TC&DB

• Adequate Nutrition

  • Daily Wt

  • Enteral/Parenteral Feeding

• Skin Integrity

  • Assess wound

  • WOC Nurse

• Preventing Complications

  • Chronic Pancreatitis 

• D/C Instructions