LGP FLSS 2.docx

Liver, Gallbladder, Pancreas FLSS

• Diagnostics

-Gallbladder Ultrasound:

-Pt complains of pain under right quadrant or in armpit

-An ultrasound gel (topical) put on pts skin

-NPO before this procedure unless it an emergency

-To rule out chest pain an EKG must be performed as well

-Cholangiogram:

-Xray to observe the gall bladder

-Catheter is inserted in the bile duct with dye to observe what the gallbladder looks like and to see if there is any gall stones.

-Check to see if the pt is allergic to dye

-Know Bilirubin levels for gallbladder

-ERCP:

-Allows the doctor to look for blockages in the bile and pancreatic ducts

-Also they can cut a slit into the sphincter to allow bile to pass through the ducts and see how it flows.

-Must obtain consent

-Once a pt has an ERCP monitor for pancreatitis

-ERCP leads to pancreatitis

-Liver Biopsy:

-This is performed to check for liver cancer or cirrhosis of the liver

-Must have a consent

-Performed with a needle underneath the rib cage

-Know how much blood is in the liver at any given time

-Watch V/S and bleeding

-S/S of bleeding: Tachy, High HR, Low BP

-Normal Signs after a Biopsy: High HR, soreness at the sight, place pt on right side

• Common Bile Obstruction

-Gallbladder stores bile

-S/S: Increased Bilirubin, Increased liver enzymes, Jaundice, White Stool

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• Cholecystitis and Lithiasis (Stones)

Open Surgery

-Most invasive, May have to stay in hospital 3-5 days

-Pt lays on table and they cut you open, larger incision

-Turn cough splint when you breathe

-DVT Prevention

-Pt may have an NG tube with an open surgery to prevent nausea

-Pt maybe also have a T tube it allows bile to go through the liver into the duodenum

-Drainage out if a T tube is expected to be red then green no more then 400-500 ml a day.

Laparoscopic Surgery

-Expect pain at the incision sit and in the left upper shoulder due to excess CO2

-Outpatient procedure

-Incision is covered with steri strips. 3-4 small incisions

-Steri strips stay on pt till they fall off do not take them off

-Adhesive band aids come off the next day

-No T or NG Tube

-Teach pt 4-6 weeks low fat diet but individualized to the pt so may be longer

-Normal Postop Turn Cough, Deep Breath, Do not lift more than 10lbs, return to work in a week

• Acute Pancreatitis

-Pancreas is located in the epigastric area to the left and it is behind everything

-Greatest Risk factors for developing it is cholelithiasis and alcohol

-Elevated Amylase and Lipase, Elevated Liver Enzymes, Increase Blood Glucose, Low Calcium

-S/S of acute pancreatitis: N/V, Low BP, High HR, Thready Pulse

-Pt is NPO in the hospital

-Pts will have an IV with crystalloids

-Do not give a lactated ringer to someone with renal problems

-Complication of pancreatitis is Atelectasis is when the lung collapses pt can develop pneumonia

-Other complications are: Hyperglycemia, Hypotension, Hypocalcemia

-Hyperglycemia: monitor with sliding scale as the doctor orders

-S/S of hypocalcemia: Rigid jaws and spasms of the hand

-Calcium binds to fatty acids causing a low serum calcium level

-Teach pt low fat diet. Milkshake with skin milk is low fat also chicken and strawberries is a good low fat diet option

-5 to 6 small meals a day, low in fat, high complex carbs, bland diet

• Chronic Pancreatitis

-Everything is the same as pancreatitis

-Supplement digestive enzymes with tablets called pancreatin/pancrealipase

-The supplements help digest proteins, lipids, and carbs

-Give it with food and do not crush

• Cirrhosis of the Liver

-Most common cause is alcohol ingestion

-Can not get rid of cirrhosis of the liver but can reduce it by reducing alcohol ingestion

-Early Cirrhosis: elevation of liver enzymes but then goes back to normal

-Priority Complication is Esophageal Varices. Most dangerous complication with cirrhosis.

-Esophageal Varices is vomiting red emesis. It is related to portal hypertension

-Blood in the Stool, Vomiting Blood

-Comes from esophageal ascites

-Prevent by lifting heavy weights, don’t bend an strain, give stool softner, or high fiber, or Beta blocker decreases BP

-1200 of blood first thing is measure VITAL SIGNS

-Maintain airway

-Ascites can be caused by cirrhosis of the liver

• Ascites

-Collection of fluid in the abdominal cavity

-Increased pressure in the liver

-Aldosterone pathways disrupted

-Fluid Volume Overload with Ascites PowerPoint Slide 72

-Pre-Paracentesis: Fluid Volume Deficit after they have had the paracentesis

-Paracentesis: needle in abdominal cavity to remove

-Monitor for vascular collapse

-Diet with Ascites: 250-1500 mg of sodium

-Med for Ascites: Spironolactone, (Spare) Furosemide (Depletes)

-Look at potassium and Sodium levels

-Monior Albumin with ascites

-Daily Weights and I’s and O’s, measure abdomen

• Hepatic Encephalopathy

-Stage 1 confused, Stage 2 hand flipping, Stage 3 coma or death

-S/S of Asterixis: confusion, coma,

-Ammonia comes from proteins chewed

-Increase ammonia level

-Ammonia crosses the Blood Brain Barrier

-Asterixis: liver flapping from increased ammonia

-Treatment: Lactulose because it balances out the PH, low protein diet

-2-3 soft bowel movemnts a day with stool softener’s to get rid of toxins

• Liver Cancer

-Caused by Metastatic Disease comes from gallbladder or bowel issues

-Also caused by Hepatitis B and C

-Prevent by controlling B and C

-Primary liver cancer is very rare

• Liver Transplant

-Pts that have primary liver cancer that only stays in the liver are able to get a transplant

-Rejection: Take anti-rejection meds like immunosuppressants. Monitor for infection with immunosuppressants.

-Watch for S/S of rejection is fever

• Liver Trauma

-Can be caused by a bruise all the way to a grade 4 laceration

-The liver has 1500ml of blood/min

-Monitor for S/S of bleeding

-Monitor V/S every 15 minutes

• Jaundice

-Increased bilirubin level causes yellowing of the skin

-3 types of jaundice:

-Hemolytic: from an increase breakdown of RBC’s, reaction to a blood transfusion

-Hepatocellular: hepatocytes don’t function right, so they don’t change the bilirubin level

-Obstructive: common bile duct blockage

-Pts w jaundice may have peritus and that is when bile salts composite under the skin

-Treatment: Tepid Baths, Wear mittens, Aloe or Oatmeal Lotion, Keep the environment Cool, Have Family members cut nails

• Hepatitis

-Hepatitis A is transmitted from fecal or oral. “A and Ass”

-People at risk for Hep A: Daycare Workers, People in Army, People that change diapers or deal with stool

-Hepatitis B is percutaneous/permuocosal, body fluids, blood, semen, etc. Mother to infant

-Hepatitis C is percutaneously (needles, tattoos, Iv drug use, etc)

-Preicteric (Early) S/S: malaise, headache, anorexia

-Lcteric Phase S/S: Jaundice, Dark Urine, Clay colored stool, Enlarged tender liver

-Standard Precautions for every type of hepatitis

• Breakdown of Questions

-11 gallbladder questions

-10 pancreas questions

-2 drug calc questions

-27 liver questions

• Lab Values Table 59.6 Pg 464

-Liver AST

-Know Potassium and Calcium Levels

-Calcium: Pancreas