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Module 8 Altered Elimination - Gastrointestinal and Biliary
What to do
STUDY ATI QUESTION AND BOOK
KNOW LABS and what it means
Know the drugs to give
Assess first then the expected outcome
Know surgery preparation
GERD, PUD, cholelithiasis, cholecystitis, cirrhosis
Pre-lecture PowerPoint and look at notes
In-person class activity
Case study
RUQ: Liver ( gallbladder), kidneys,
Pain in back N/V previous episode
Onset pain after eating
Bowel sounds active
Abdominal guarding
Light clay color urine, light jaundice, obese, 144/100 BP, 132 HR, No fever,
Cirrhosis: cause of jaundice
Gallstones
Complication Cirrhosis, Collaborative Care Roles, and Discharge Teaching
Complications of Cirrhosis
Cirrhosis is a progressive liver disease that can lead to severe complications, including:
Portal Hypertension – Increased pressure in the portal vein leading to varices and ascites.
Esophageal and Gastric Varices – Dilated veins in the esophagus and stomach that may rupture, causing life-threatening bleeding.
Ascites – Fluid accumulation in the peritoneal cavity, leading to abdominal distention and respiratory distress.
Hepatic Encephalopathy – Accumulation of ammonia and toxins in the blood affecting brain function, causing confusion, lethargy, and possible coma.
Coagulopathy and Bleeding Tendencies – Impaired production of clotting factors leading to an increased risk of bleeding and bruising.
Jaundice – Yellowing of the skin and sclera due to bilirubin buildup.
Hepatorenal Syndrome – Kidney failure due to decreased blood flow to the kidneys.
Spontaneous Bacterial Peritonitis (SBP) – Infection of ascitic fluid, leading to fever and worsening liver function.
Collaborative Care Roles
Managing cirrhosis involves a multidisciplinary approach:
Physician/Gastroenterologist/Hepatologist – Diagnoses, monitors liver function, prescribes medications, and manages complications.
Nurse – Provides patient education, monitors for complications, administers medications, and supports nutritional needs.
Dietitian – Assists with dietary modifications, including sodium and protein restrictions to prevent complications like ascites and encephalopathy.
Pharmacist – Reviews medications to avoid hepatotoxic drugs and ensures proper dosing.
Social Worker/Case Manager – Assists with discharge planning, financial resources, and support services.
Physical Therapist – Helps maintain mobility and prevent muscle wasting.
Discharge Teaching
Dietary Modifications
Low sodium diet to prevent fluid retention.
Adequate protein intake but monitored for hepatic encephalopathy.
Avoid alcohol and hepatotoxic medications (e.g., NSAIDs, and acetaminophen in high doses).
Medication Adherence
Diuretics (e.g., spironolactone, furosemide) for ascites.
Lactulose for hepatic encephalopathy (monitor for diarrhea).
Beta-blockers (e.g., propranolol) for variceal bleeding prevention.
Signs of Complications
Increased abdominal girth, weight gain, or difficulty breathing (ascites).
Black, tarry stools or vomiting blood (variceal bleeding).
Confusion, sleep disturbances, or personality changes (hepatic encephalopathy).
Jaundice or severe itching.
Lifestyle Changes
Avoid alcohol and smoking.
Maintain physical activity within tolerance.
Regular follow-up appointments and lab tests (e.g., liver function tests, INR, albumin).
In Class PowerPoint
GERD
EGD or other words endoscopy with moderate sedation
Make sure the patient has a good gag reflex → how to check: The patient needs to swallow
Check abnormal tissue and look at everything
Medication
Omeprazole: PPI: Taken 30 minutes before your meal
Famotidine Pepcid
Regalan: Nausea and vomiting
Peptic Ulcer
Right after eating, they have a sudden pain in the stomach
The mucosal lining is damaged
S/S: Abdominal pain, lead to GERD, Blood in vomit and urine, burning in the throat
Once the peptic ulcer has been a while it will have blood
Melena: Blood present
Pain in the abdominal area
Nurse intervention
I/O and fluid and electrolytes
Blood transfer
H & H: low hematocrit and hemaglobin
Below 8 is when they need it
Will need a consent form
IV infusion as well
NPO until you get orders otherwise
Biliary system: Gall bladder, hepatic duct, cystic duct, common bile duct
Bile is produced in the gallbladder
Concentration of bile
Bile: Green-yellow fluid (consisting of waste product, cholesterol, and bile salts - bilirubin)
drain waste product from the liver into the duodenum and help in digestion with the controller releasing the bile
Bile stones can block
Cholelithiasis: Presence of stone in the gallbladder
Formation of calcium salt which gallstones hardened and blocked passage
Only knows when pain starts and pain is usually in the back
Women are more common: Female, fertile, fat, forty
RUQ pain
Complication: Gallbladder rupture
Liver test
Nursing management: monitor pain level, dietary intake
Nutritional flare-up ( fried food, cheese)
Types of Stones
Pure cholesterol Stones: Supersaturation with 90% of cholesterol
Pigment stone at 90% bilirubin
Diagnostics Test: abdominal stones are found with ultrasound, laparoscopic cholecystectomy ( look at labs before)
WBC: maybe an increase
Bilirubin elevated
ALT/AST elevated
Amylase and lipase elevated
Medication
Colethiasis lithotripsy
Cholecystitis
Pathophysiology: Inflammation of gallstones caused by obstriction stones or biliary sludge build up in the gallbladder
Acute cholecystitis: Severe pain
Chronic: Reoccurance of the pain
S/S: Sharp RUQ quadrant, loose color stool, heartburn
Total obstruction
Bilirubin will be elevated
Reports light clay color is that bile ducts are blocked
Murphy Sign is only done with a physician
Cholecystitis
Preop
Consent form
Prep form
NPO after midnight
Stop taking certain medications and supplement
Post-op
Monitor for bleeding, pain management
Transient or temporary N/V
SURGEONS OPEN UP FOR THE FIRST TIME NEVER THE NURSE
Mark the fluid so you can see the spread
Laparoscopic
Return to normal activity 1-week time driving, light lifting, and working
Some patients stay overnight and leave in the morning
IS turn 2q hours
Prevent pain, and infection, monitor WBC
Keep the tube client in the Fowler position to promote the gravity drain of the bile.
Assess the skin for leakage.
No active bowel sounds till moving
Teaching
Eat small frequent meals, reduce weight, diet
Complication
Going into septic shock if not treated
Collaborative care
Ultrasound, HIDA Scan: Takes image of hepatic system, Percutaneous transhepatic cholangiography
NPO: cause of aspiration, exagerbation
Low intermitted suction for NG tube and strict I/O
No Morphine but use Dilaudid
Multiple antibiotics are going to be used
Therapies
Laparoscopic Cholecystectomy
Use 90% of the time
Incisional cholescystemcomty
Discharge teaching
Dietary teaching low-fat dieth with weight-reduction plan
Take analgesic
Make sure the patient takes meds before the pain starts
The patient doesn’t wanna breathe since it can intensify the pain os breathing is shallow
Cirrhosis ( Has a lot of questions) AS IYITES
Excessive scarring of fibrotic tissue in the liver leads to liver dysfunction and occlusion of the ducts
Complication: Hepatic
NSAID
Biopsy of liver
Medication: Potassium sparring diuretic, Lactulose, Beta blocking agents, anti-inflammatory drugs, antibiotics
Nursing management: Daily weight and I/O
4 different stages
1
2
3
4
Look for LOC, jaundice, ammonia level ( 20-80), Lactulose ( absorbed the ammonia and secretes it in stool)
Albumumin low results in fluid retention in the body
Complication of cirrhosis
Canvas PP
Group 1 - GERD
Explain what GERD is in your concept map.
Test your knowledge:
The nurse explains to the patient what GERD disorder is:
A. Results in acid erosion and ulceration of the esophagus caused by frequent vomiting
B. Will require surgical wrapping or repair of the pyloric sphincter to control the symptoms
C. Is the protrusion of a portion of the stomach into the esophagus through an opening in the diaphragm
D. Often involves relaxation of the Lower Esophageal Sphincter (LES), allowing stomach contents to back up into the esophagus.
Answer: D – Often involves relaxation of the Lower Esophageal Sphincter (LES), allowing stomach contents to back up into the esophagus.
Medication Information:
Oxybutynin (Ditropan XL) - Anticholinergic: Blocks/reduces neurotransmitters in the brain and treats overactive bladder and irritable bowel syndrome.
Prilosec - Proton-pump inhibitor (PPI): Decreases stomach acid and helps the esophagus heal.
Reglan - Prokinetic drug: Prevents delayed gastric emptying by improving pressure in the lower esophageal sphincter and improves peristalsis of the GI tract.
Pepcid - Histamine H2 blocker: Helps relieve heartburn by reducing acid in the stomach. Begins to work in 15-30 minutes.
Antihistamine and Antacid
It can treat ulcers, gastroesophageal reflux disease (GERD), and conditions that cause excess stomach acid. It can also treat heartburn caused by acid indigestion.
Pepcid – helps to prevent stress ulcers.
PPIs include lansoprazole (Prevacid), omeprazole (Prilosec), pantoprazole (Protonix), rabeprazole (AcipHex), and esomeprazole (Nexium). They are prescribed to both prevent and treat ulcers in the duodenum (where most ulcers develop) and the stomach.
Group 2 – Peptic Ulcer
Explain what PUD is in your concept,t ma.?
Test your knowledge:
A patient has a peptic ulcer and has undergone esophagogastroduodenoscopy (EGD). The nurse places the highest priority on which of the following as part of the client's care plan?
A. Checking for the return of a gag reflex
B. Position the client supine and flat
C. Administration of an analgesic
D. Decrease or absent peripheral pulses
Answer: A – Checking for the return of a gag reflex
Rationale:
The gag reflex is critical after an EGD to ensure that the patient can safely swallow and that no aspiration occurs.
Esophagogastroduodenoscopy (EGD)
Purpose: Examines the lining of the esophagus, stomach, and duodenum (first part of the small intestine).
Indications:
Abdominal pain
Difficulty swallowing
Prolonged nausea & vomiting
Heartburn
Unexplained weight loss
Anemia
Blood in bowel movements
Procedure:
The endoscope is inserted through the mouth and into the stomach.
Used to diagnose and treat upper GI tract disorders.
Sedation:
Conscious Sedation (Moderate Sedation):
Drowsy and forgetful, able to follow simple instructions while asleep.
Deep Sedation:
Puts the patient into a deeper sleep, ensuring no discomfort.
Patient Experience:
Sedation relaxes the patient and subdues the gag reflex.
Moderate to deep sleep during the procedure.
This test is important for diagnosing and managing upper GI tract conditions, with sedation ensuring the patient's comfort.
Biliary System
What is the Biliary System?
Gall Bladder
Hepatic Duct
Cystic Duct
Common Bile Duct
Involved in the production and transportation of bile.
Test your Knowledge:
Biliary /disorder -refers to diseases affecting the bile ducts, gallbladder, and other structures involved in the production and transportation of bile. Bile is a fluid produced by the liver that aids digestion.
Bile duct strictures may present with nonspecific signs and symptoms of obstructive jaundice, abdominal pain, nausea, vomiting, fever, and leukocytosis. The cause of bile duct strictures may be one of the myriads of diagnosis, which includes benign and malignant etiologies.
The causes of benign bile duct strictures are usually surgical inexperience, failure to recognize abnormal biliary anatomy and congenital anomalies, acute inflammation, misplacement of clips, excessive use of cautery, and excessive dissection around the major bile ducts, resulting in ischemic injury.
What do you think a Biliary Disorder is?
Functions of the Biliary System:
Drains waste products from the liver into the duodenum.
Helps in digestion with the controlled release of bile.
Bile – Greenish-yellow fluid consisting of waste products, cholesterol, and bile salts (bilirubin).
Bile is a liquid released by the liver.
It contains cholesterol, bile salts, and waste products such as bilirubin.
Bile salts help your body break down (digest) fats.
Bile passes out of the liver through the bile ducts and is stored in the gallbladder. After a meal, it is released into the small intestine.
When the bile ducts become blocked, bile builds up in the liver, and jaundice (yellow color of the skin) develops due to the increasing level of bilirubin in the blood.
Secreted by liver cells to perform two primary functions:
To carry away waste (bilirubin).
To break down fats during digestion.
Bile Salt:
The actual component that helps break down and absorb fats. Excreted from the body as feces (which gives them their dark brown color).
Group 3 – Cholelithiasis
Gall Bladder Disease- gallstones present.
Clinical Manifestations- Cholelithiasis:
Stationary or Mobile - when the stone is lodged in the duct or when it is moving through the ducts
Severe steady pain- RUQ
Excruciating pain with tachycardia, diaphoresis, and extreme physical weakness
Occurs often 3-6 hours after a high-fat meal or when the patient lies down
Overtime of bile overflow blockage leads to liver fibrosis, and cirrhosis occurs
Explain what GERD is in your concept map.
What are three types of Cholelithiasis?
Cholelithiasis: Presence of stones in the gallbladder.
Most common biliary disorder, affecting more than 20 million Americans each year.
Medical costs: $6.3 billion.
Gallstones occur worldwide, most commonly among North American Indians and Hispanics, but are low in Asian and African populations.
10% of Americans have cholecystitis due to gallstones.
More common in women.
4 Fs: Female, Fertile, Fat, Forty.
Pathophysiology of Cholelithiasis:
Overproduction of cholesterol, bilirubin, and calcium salts forms gallstones.
Gallstones harden and block passage.
Stones may migrate to the cystic or common bile ducts, causing pain during passage.
Obstruction can lead to cholecystitis.
Cholesterol Supersaturation:
Essential for gallstone formation, it occurs when cholesterol concentration in bile exceeds its solubility.
Excessive Cholesterol Biosynthesis:
Common in obese individuals.
Increased cholesterol production leads to supersaturation.
Defective Conversion of Cholesterol to Bile Acids:
Low Activity of Cholesterol 7α-Hydroxylase:
A key enzyme for bile acid biosynthesis and cholesterol elimination.
In non-obese individuals, reduced enzyme activity leads to excessive cholesterol secretion, contributing to stone formation.
Interruption of Enterohepatic Circulation of Bile Acids:
Disruption of bile acid recycling increases bile saturation, promoting cholesterol gallstone formation.
Overnight Fasting:
Temporary interruption of enterohepatic circulation increases the cholesterol/phospholipid ratio in liver-secreted vesicles.
Estrogen Treatment:
In women, estrogen reduces bile acid synthesis, increasing the risk of cholesterol supersaturation and gallstone formation.
These mechanisms contribute to the formation of cholesterol gallstones through various pathways related to cholesterol production, bile acid metabolism, and bile acid circulation.
Clinical Manifestations:
Stationary or Mobile: Depends on whether the stone is lodged in the duct or moving through.
Severe, steady pain in the RUQ.
Excruciating pain with tachycardia, diaphoresis, and extreme physical weakness.
Pain often occurs 3-6 hours after a high-fat meal or when the patient lies down.
Over time, bile overflow blockage leads to liver fibrosis and cirrhosis.
Radiology Results:
The patient was taken for an abdominal ultrasound.
Results: Several retained stones in the common bile duct.
Mrs. Mills is scheduled for a laparoscopic cholecystectomy in the morning.
What lab results should you look for?
WBCs: May be elevated.
Bilirubin levels: Elevated.
ALT/AST: Liver enzymes may be elevated.
Amylase and Lipase May be elevated.
Normal Lab Values:
What is the normal WBC?
What is the normal bilirubin level?
Treatment for Cholelithiasis
Cholelithiasis (Gallstones)
Primary Clinical Manifestation: Cholecystitis (inflammation of the gallbladder) is the main complication of cholelithiasis.
Risk Factors for Cholelithiasis
Age:
Increasing age is associated with a higher prevalence of gallstones.
Gallstones are 4-10 times more frequent in older individuals.
Biliary cholesterol saturation increases with age due to reduced activity of cholesterol 7α hydroxylase.
Gender, Parity, and Oral Contraceptives:
Women are nearly twice as likely as men to experience cholelithiasis, especially during their fertile years.
Increased estrogen levels (from pregnancy, hormone therapy, or oral contraceptives) raise cholesterol levels in bile and reduce gallbladder movement, increasing gallstone formation.
Genetics:
Racial differences exist in cholesterol gallstone prevalence:
Low in Asian and African populations (<5%).
Intermediate in European and Northern American populations (10-30%).
High in Native American populations, such as Pima Indians (30-70%).
Obesity:
Obesity, particularly in women, increases the risk of cholesterol gallstones.
It raises biliary cholesterol secretion due to increased HMG-CoA reductase activity.
The risk is strongest in young women, while slimness provides protection.
Rapid Weight Loss:
Weight loss of 10-25% over a few weeks increases the risk of gallstones.
The liver secretes extra cholesterol, and fat mobilization from adipose tissue contributes to cholesterol secretion.
Gallbladder contraction is reduced, promoting stasis and favoring gallstone formation.
Short-term fasting increases the cholesterol saturation of gallbladder bile, and long-term fasting may lead to stasis and sludge formation.
Physical Activity:
Regular exercise helps with weight control and improves metabolic abnormalities related to obesity and gallstones.
Sedentary behavior increases the risk of cholecystectomy.
Drugs:
Fibric acid derivatives (e.g., clofibrate) increase biliary cholesterol saturation, raising the risk of gallstones.
Proton pump inhibitors (PPIs) can decrease gallbladder function and may contribute to gallstone formation.
Ceftriaxone has a known lithogenic role.
Diabetes:
People with diabetes often have high triglyceride levels, increasing the risk of gallstones.
Diabetic neuropathy impairs gallbladder function, and insulin therapy may raise the lithogenic index.
Melatonin deficiency may contribute to gallstones, as melatonin inhibits cholesterol secretion from the gallbladder and has antioxidant effects.
These factors contribute to the formation of cholesterol gallstones through mechanisms involving cholesterol secretion, bile acid metabolism, and gallbladder function.
Scenario:
The patient with right upper quadrant abdominal pain has an abdominal ultrasound revealing cholelithiasis. What should the nurse expect to do for this patient?
A. Prevent all oral intake.
B. Control abdominal pain.
C. Provide enteral feedings.
D. Avoid dietary cholesterol.
Answer: B – Control abdominal pain.
Rationale: Patients with cholelithiasis can have severe pain, so controlling the pain is essential until the problem can be treated.
Group 4 – Cholecystitis
Explain what Cholecystitis is in your concept map.
What is the Pathophysiology of Cholecystitis?
Inflammation of gallstones caused by obstruction or biliary sludge buildup in the gallbladder.
What are the 3 Types of Cholecystitis?
Acute Cholecystitis: Begins suddenly, resulting in severe, steady pain in the upper abdomen.
Chronic Cholecystitis: Recurring attacks of pain, typically dull in the right upper quadrant, radiating to the waist and back.
Acute Superimposed on Chronic: Acute cholecystitis may occur on top of pre-existing chronic cholecystitis.
Pathophysiology of Cholecystitis:
Critically ill: dehydration, fever, prolonged absence of oral intake à decrease or absence of cholecystokinin-induced GB contraction
Cholecystitis happens when a digestive juice called bile gets trapped in your gallbladder. In most cases, this happens because lumps of solid material (gallstones) are blocking a tube that drains bile from the gallbladder. When gallstones block this tube, bile builds up in your gallbladder.
Risk Factors:
Older adults.
Critical illness.
Prolonged immobility and fasting.
Prolonged parenteral nutrition.
Diabetes mellitus (DM).
Adhesions.
Neoplasms (new abnormal growth tissue).
Opioids.
Clinical Manifestations of Cholecystitis:
Chief Symptom:
Pain: Sharp, cramping, or dull pain in the upper right or upper middle abdomen.
Constant and increases in severity over the first half hour, typically lasting 1-5 hours.
Pain can radiate to the right upper back or between the scapulae.
Severe pain may occur abruptly, often at night or after a fatty meal.
Additional Symptoms:
Leukocytosis (elevated white blood cell count) and fever with chills due to inflammation.
Epigastric tenderness and abdominal rigidity.
Cramping and bloating.
Nausea and vomiting.
Loose, light-colored stools.
Fat intolerance, indigestion, heartburn, and flatulence.
Jaundice.
Chronic Cholecystitis:
Total Obstruction: Related to bile blockage.
No bilirubin reaches the small intestine to be converted to urobilinogen.
Bilirubin is excreted by the kidneys, causing dark amber to brown urine.
Chronic Cholecystitis
Symptoms:
Dull right upper abdominal pain, often radiating around the waist to the mid-back or right scapular tip.
Pain typically occurs after eating fatty foods or large meals.
Causative Factors:
Inflammation of the mucous lining or the entire wall of the gallbladder.
Causative Agents:
E. Coli, Streptococci, and Salmonella (bacteria that may travel via the vascular or lymphatic route).
Other Contributing Factors:
Adhesions (scar tissue from previous surgeries or infections).
Neoplasm (tumors affecting the gallbladder).
Anesthesia (can contribute to decreased gallbladder function).
Decreased Function:
Occurs if significant fibrosis (scarring) develops in the gallbladder wall, leading to impaired contraction and emptying of the gallbladder, which can further contribute to symptoms.
Chronic cholecystitis is a condition where the gallbladder's functionality is compromised due to ongoing inflammation, fibrosis, and possible bacterial infection.
Answering Knowledge Check:
Elevated white blood cell count:
Rationale: The white blood cell count should be elevated in clients with chronic inflammation.
WBC: 4.5 TO 11
Nurse Report from ER – What Finding Alerts the Nurse of Bile Blockage?
A. Reports light, clay-colored stools for 1 week.
B. Reports right upper quadrant pain.
C. Notable fatigue.
D. Voids medium amber urine without difficulty.
Answer: A – Reports light, clay-colored stools for 1 week.
Rationale: Light-colored or clay-colored stools are often seen in diseases of the liver or bile ducts. Lack of bile can cause the stool to lose its brown color, resulting in pale or chalky stools.
Murphy’s Sign:
Complications of Cholecystitis:
Gallbladder rupture.
Biliary fistula.
Pancreatitis.
Peritonitis.
Cholangitis (infection of the bile ducts).
Collaborative Care Roles:
Physician: Diagnosis, treatment plan, and surgery (e.g., cholecystectomy).
Nurse: Monitor vitals, manage pain, assess for complications, administer antibiotics, and provide patient education.
Dietitian: Provide dietary counseling, particularly for fat intake, post-surgery.
Pharmacist: Ensure appropriate medication for pain and infection control.
Discharge Teachings:
Low-fat diet post-surgery.
Wound care instructions.
Signs of infection to watch for (fever, redness, swelling).
Follow-up care and check-ups after cholecystectomy.
Pain management at home.
Importance of medication adherence (antibiotics, pain management).
Diagnostic Studies:
Abdominal X-ray: Can show gallstones, but less sensitive than ultrasound.
Ultrasound (US): Common diagnostic test for gallstones; preferred for jaundiced patients or those allergic to contrast.
CT Scan: Used when ultrasound results are inconclusive or to look for other complications.
ERCP (Endoscopic Retrograde Cholangiopancreatography): Used to diagnose and treat bile duct issues, such as blockages or stones.
CBC (Complete Blood Count): To check for signs of infection or inflammation.
Bilirubin: Elevated levels can indicate bile duct obstruction.
Liver Function Tests (LFTs): Elevated levels may suggest liver involvement due to bile duct obstruction.
Amylase/Lipase: Elevated in cases of pancreatitis.
HIDA Scan: Takes images of hepatobiliary organs, used to assess gallbladder function.]
A HIDA scan, which stands for hepatobiliary iminodiacetic acid scan, creates pictures of your liver, gallbladder, biliary tract, and small intestine. A HIDA scan can also be called Chol scintigraphy, hepatobiliary scintigraph,y, or hepatobiliary scan.
HIDA scan is a type of imaging study called a nuclear medicine scan
Percutaneous Transhepatic Cholangiography (PTCA): Done after ultrasound to detect bile duct blockage and insert stent if needed.
ERCP
Direct visualization of GB, cystic duct, common hepatic duct, common bile duct
Fiberoptic endoscope to visualize the biliary tree, remove stones, drain the bile sludge, collect biopsies, and place a biliary drainage bag
Bile can be sent for C/S
U/S- Abdominal Ultrasonography – most common test
Pharmacologic Therapy:
Antibiotics: Levofloxacin and Metronidazole for prophylactic coverage against common organisms.
Antiemetics: Promethazine or Prochlorperazine for nausea control.
Pain Control:
Oxycodone or Acetaminophen for pain relief.
Avoid morphine due to its potential to cause sphincter of Oddi spasm.
Preferred options: Dilaudid, Demerol, or Fentanyl.
Nurse’s Priority in Mrs. Mills’ Case (Vital signs at midnight: BP 105/69, HR 136, Temp 98.8, RR 24):
Answer: D – Start 0.9% NS as prescribed.
Rationale: Mrs. Mills is NPO (nothing by mouth), so hydration and fluid resuscitation are necessary to correct electrolyte and fluid imbalances.
Other Options:
A. Encourage slow, deep breaths – helps with anxiety, but is nott a priority at this moment.
B. Prep for surgery – surgery is scheduled for the morning, so stabilization takes precedence.
C. Call the physician and provide SBAR (Situation, Background, Assessment, Recommendation) – important if the condition worsens but not the priority here.
Preoperative Care – Cholecystectomy:
Consent Form: Ensure the patient understands the procedure and risks involved.
Bowel Prep: The patient may need to drink a solution to clean out the intestines before the procedure.
NPO After Midnight: The patient should refrain from eating or drinking after midnight before surgery.
Stop Certain Medications/Supplements: Discontinue medications or supplements that may increase the risk of bleeding, such as anticoagulants.
Surgical Options:
Laparoscopic Cholecystectomy: Preferred method for 90% of cases due to smaller incisions, quicker recovery, and less postoperative pain.
Incisional (Open) Cholecystectomy: This may be required if laparoscopic surgery is not an option (e.g., severe inflammation or scarring).
Surgical Treatment Goal: To remove the gallbladder and resolve issues related to cholecystitis.
Postoperative Care – Cholecystectomy:
Monitor for Bleeding: Watch for signs of bleeding or complications at the incision site.
Pain Management: Address shoulder pain caused by CO2 used during surgery, as it can irritate the diaphragm.
Transient Nausea and Vomiting: Common for 1-2 days after surgery.
Activity Resumption:
Laparoscopic Procedure: Most patients return to normal activities (driving, light lifting, work) within 1 week.
Open Procedure: Requires 4-6 weeks to return to normal activities.
Post-Op Follow-Up: Schedule an appointment with the surgeon within 2-3 weeks after the operation.
Postoperative/Collaborative Care:
Pulmonary Toilet: Encourage deep breathing exercises (TCDB), incentive spirometry (IS), and turning every 2 hours to prevent pneumonia.
Infection Prevention: Monitor WBC levels, assess for peritonitis (temp > 100°F), and keep the incision clean and dry.
Fowler’s Position for T-Tube: Helps promote gravity drainage of bile if a T-tube is placed.
Bile Leakage Monitoring: Assess for signs of bile leakage, including skin inflammation.
Bile Drainage: Report bile drainage > 500 ml after 3 days.
Stool Monitoring: Monitor stool color, consistency, and frequency; pale stools may indicate ongoing bile duct obstruction.
Nutritional Therapy:
Eat small, frequent meals.
Low-fat diet, high in fiber, to improve digestion after gallbladder removal.
Gradually reduce weight, if needed.
Discharge Teaching – Laparoscopic Cholecystectomy:
Lower-Fat Diet: A low-fat diet is recommended for several weeks as it may be better-tolerated post-surgery.
Work and Activities: Normal activities can typically resume in 1 week for laparoscopic surgery and 3 weeks for open surgery.
Bile-Colored Drainage: Drainage from the incision should not be bile-colored. If so, contact a healthcare provider.
Incision Care: Keep the bandages on and the incision site dry until healed.
Nurse’s Priority Question:
What information should the nurse include for discharge teaching after laparoscopic cholecystectomy?
Answer: A – A lower-fat diet may be better tolerated for several weeks.
Rationale: Although the usual diet can be resumed, a low-fat diet is usually better tolerated for the first several weeks after surgery to help the digestive system adjust.
Mrs. Mills - Home Care Teaching:
Dietary Teaching:
Follow a low-fat diet and incorporate a weight reduction program to prevent further complications and improve recovery.
Analgesic Use:
Take prescribed analgesics as directed to manage postoperative pain.
Prevent Fluid & Electrolyte Imbalance:
Monitor for signs of dehydration or electrolyte imbalance and maintain proper hydration.
Monitor for Obstruction:
Watch for changes in stool and urine color, jaundice, or pruritus, which may indicate bile duct obstruction.
Avoid Heavy Lifting:
Avoid heavy lifting for 4-6 weeks to allow proper healing and prevent strain on the incision site.
Follow-Up Appointments:
Schedule and attend follow-up healthcare appointments as recommended by the surgeon.
Test Your Knowledge:
Which assessment data indicates to the nurse that the client recovering from an open cholecystectomy may require pain medication?
A. The client’s pulse is 65 beats per minute
B. The client has shallow respirations
C. The client’s bowel sounds are 20 per minute
D. The client uses a pillow to splint when coughing
Answer: B. The client has shallow respirations
Rationale:An open cholecystectomy involves a large incision, often under the diaphragm. Deep breathing can cause discomfort and pressure on the incision site.
Shallow respirations are a sign of inadequate pain control because the client is trying to avoid deep breaths due to pain at the incision site. The nurse should intervene to manage the pain more effectively.
Group 6 - Cirrhosis:
Explain What Is Your Concept Map?
Cirrhosis is a chronic liver disease characterized by progressive liver damage, leading to scarring (fibrosis) and impaired liver function. This condition often results from long-term liver inflammation, commonly caused by chronic hepatitis, alcohol abuse, or non-alcoholic fatty liver disease (NAFLD).
Cirrhosis: A late stage of liver disease characterized by permanent scarring and liver damage. It can lead to liver failure and, if left untreated, can be fatal.
Stages of Cirrhosis:
Stage 1: Inflammation
The liver becomes inflamed due to damage from factors like alcohol, viral infections (e.g., hepatitis), or toxins.
This stage may not present with obvious symptoms but can gradually worsen.
Stage 2: Scarring
Inflammation leads to scarring (fibrosis) of liver tissue.
Scarring disrupts liver function, but the liver can still compensate at this stage. Symptoms may begin to appear.
Stage 3: Cirrhosis
Extensive scarring occurs, causing significant damage to liver function.
Symptoms like jaundice, fatigue, abdominal swelling, and confusion (due to toxin buildup) become more apparent.
At this stage, liver function is seriously impaired.
Stage 4: Liver Failure / End-Stage Liver Disease (ESLD)
The liver is no longer able to perform its essential functions, such as detoxifying the body, producing proteins, and regulating metabolism.
Complications like bleeding, infections, and organ failure may occur.
Liver transplantation may be required.
Stage 5: Liver Cancer (Hepatocellular Carcinoma)
Chronic cirrhosis increases the risk of liver cancer.
Tumors may form in the liver, further compromising its function and leading to severe complications.
Cirrhosis is a progressive disease that can lead to liver failure and cancer. Early detection and management can help slow progression, but at advanced stages, the prognosis is often poor without a liver transplant.
Test Your Knowledge:
The nurse is caring for a client diagnosed with chronic hepatitis, receiving the medication lactulose. Which laboratory results indicate the medication is achieving the desired therapeutic effect?
A. Decreased serum bilirubin
B. Decreased serum alanine aminotransferase (ALT)
C. Increased serum albumin
D. Decreased serum ammonia
Answer: D. Decreased serum ammonia
Rationale:Normally, the liver converts ammonia (a by-product of amino acid metabolism) into urea for excretion via the kidneys. In cirrhosis and other liver conditions, the liver’s ability to perform this function is impaired, leading to the buildup of ammonia in the bloodstream, which can cause hepatic encephalopathy (confusion, altered mental status).
Lactulose is used to reduce blood ammonia levels by drawing ammonia into the bowel, where it is excreted. A decreased serum ammonia level indicates that lactulose is effectively lowering ammonia and thus improving the patient’s mental status (more alert and oriented, less delirium).
Group 7 - Cirrhosis:
Complications of Cirrhosis:
Ascites: Accumulation of fluid in the peritoneal cavity due to portal hypertension, low albumin levels, and fluid retention.
Jaundice: Yellowing of the skin, sclera, and mucous membranes due to impaired bilirubin conjugation in the liver.
Hepatic Encephalopathy: Cognitive impairment caused by the buildup of toxins like ammonia.
Variceal Bleeding: Enlarged blood vessels in the esophagus or stomach that can rupture, causing severe bleeding.
Infections: Increased risk of bacterial infections due to impaired immune function and ascitic fluid.
Coagulation Defects: The liver’s reduced ability to produce clotting factors increases the risk of bleeding and bruising.
Collaborative Care Roles:
Nurses: Monitor vital signs, manage ascites (diuretics, paracentesis), assess for signs of bleeding, and provide patient education on fluid and sodium restriction.
Physicians: Diagnose and manage the underlying cause of cirrhosis (e.g., hepatitis, alcohol use) and decide on interventions such as medications or surgery.
Dietitians: Provide dietary counseling to manage fluid retention, low sodium diet, and malnutrition.
Social Workers: Assist with resources for managing chronic illness and supporting lifestyle changes.
Pharmacists: Ensure appropriate medications for managing symptoms, including diuretics, lactulose, and other supportive treatments.
Discharge Teachings:
Diet: Low-sodium diet to manage ascites and fluid retention. Encourage small, frequent meals to avoid pressure on the abdomen.
Fluid Restrictions: Monitor fluid intake due to ascites and manage dehydration risk.
Medications: Teach the patient about medications, especially diuretics (to manage fluid) and lactulose (to reduce ammonia levels).
Signs of Complications: Teach the patient and caregivers to recognize signs of infection, bleeding, or worsening jaundice and to seek immediate medical care.
Alcohol Avoidance: Advise the patient to avoid alcohol, as it can worsen liver damage.
Follow-up: Ensure regular follow-up visits for monitoring liver function, ascites, and overall health.
Shift Report Scenario:
You are receiving a gift report on a patient with cirrhosis and ascites. The nurse tells you the patient’s bilirubin levels are very high. Based on this, what assessment findings may you expect to find? Select all that apply:
Answer: B, C, D, E, GB. Yellowing of the skin, sclera, and mucous membranes (jaundice)
C. Dark brown urine (bilirubin in the urine)
D. Clay-colored stools (absence of bilirubin in the stool)
E. Elevated bilirubin levels
G. Decreased albumin levels (due to the liver’s inability to produce albumin)
Rationale:
High bilirubin levels are due to the liver’s inability to properly conjugate and excrete bilirubin. The damage to hepatocytes prevents bilirubin from being properly processed and secreted into the bile. Instead, bilirubin leaks into the blood, leading to jaundice (yellowing of skin, eyes, and mucous membranes), dark brown urine, and clay-colored stools (due to the absence of bilirubin in the stool). Additionally, low albumin levels are a concern, as the liver is no longer able to produce adequate albumin, contributing to fluid retention and ascites.
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