Chapter 44 Assessment & Management of Patients w/ Biliary Disorders

Question 1

Organs Involved in the Biliary System

Answer 1

Gallbladder: Bile

Pancreas
Exocrine: amylase, trypsin, lipase,
secretin
Endocrine: insulin, glucagon,
somatostatin

Question 2

Gallbladder Functions

Answer 2

Store & excrete bile

Question 3

Cholecystokinin (CKK)

Answer 3

Major hormone that stimulates the gallbladder contract & release digestive enzymes

Question 4

Bile

Answer 4

Composed of H2O & electrolytes along w/ lecithin, fatty acids, cholesterol, bilirubin, & bile salts

Assist in emulsification of fats in the distal ileum

Question 5

Enterohepatic Circulation

Answer 5

1) Food enters the duodenum

2) Gallbladder contracts & sphincter of Oddi relaxes

3) Sphincter relaxation allows bile to enter the intestines

4) Bile salts work w/ cholesterol to aid in emulsification of fats in distal ileum

5) Reabsorption back into portal blood for hepatic return
- Once again excreted in bile

Question 6

If the flow of bile is impeded…

Answer 6

…bilirubin does NOT enter the intestine & blood levels of bilirubin increase

Question 7

What occurs as a result of bilirubin blood level increase?

Answer 7

It causes increased renal excretion of urobilinogen & decreased excretion of stool
- Urobilinogen occurs from the conversion of bilirubin in the small intestine

Question 8

Cholodocholithiasis

Answer 8

Stones in the common bile duct

Question 9

Cholecystitis

Answer 9

Inflammation of the gallbladder
- Can either be acute or chronic

Question 10

Clinical Manifestations of Cholecystitis

Answer 10

Pain

Tenderness

Rigidity of the right upper abdomen, can radiate to midsternal area or right shoulder

Nausea

Vomiting

Empyema (pus) can develop

Question 11

Cholelithiasis

Answer 11

Presence of stones in the gallbladder
- Pigment stones
- Cholesterol stones

Question 12

Risk Factors for Cholelithiasis

Answer 12

Cystic fibrosis

Diabetes

Frequent changes in weight

Ileal resection or disease

Low-dose estrogen therapy:carries a small increase in the risk of gallstones

Obesity

Rapid weight loss (leads to rapid development of gallstones and high risk of symptomatic disease)

Treatment w/ high-dose estrogen (e.g., in prostate cancer)

Women, especially those who have had multiple pregnancies or who are of Native American or U.S. southwestern Hispanic ethnicity

Question 13

Pigment Stones

Answer 13

Unconjugated pigments in bile form stones

Account for 10-15% of cases in the United States

Cannot be dissolved and must be removed surgically

Question 14

Cholesterol Stones

Answer 14

Account for 75% of gallbladder disease

Decrease bile acid synthesis and increased cholesterol synthesis

Bile becomes supersaturated w/ cholesterol and form stones

Question 15

Clinical Manifestations of Cholelithiasis

Answer 15

None or minimal symptoms, acute or chronic

Pain-excruciating upper right abdominal pain that radiates to back or shoulder

Biliary colic-caused by contraction of the gallbladder Jaundice-obstruction of the bile duct

Changes in urine or stool color-dark urine and clay-colored stools

Vitamin deficiency, fat soluble (vitamins A, D, E, and K)-obstruction interferes w/ absorption of the fat-soluble vitamins

Question 16

Pathological Process of Calculous Cholecystitis

Answer 16

Cause of more than 90% of cases of acute cholecystitis

1) Gallbladder stone obstructs bile outflow

2) Bile remaining in the gallbladder initiates a chemical reaction
- Autolysis & edema occur

3) Blood vessels in the gallbladder are compressed-> Compromises its vascular supply
- Gangrene of the gallbladder w/perforation may occur

Question 17

Acalculous Cholecystitis

Answer 17

Describes acute gallbladder in the absence of gallstone obstruction

Occurs after:
- Major surgical procedures
- Orthopedic procedures
- Severe trauma or burns

Question 18

Other Factors Associated w/ Acalculous Cholecystitis

Answer 18

Torsion

Cystic duct obstruction

Primarily bacterial infections of the gallbladder

Multiple blood transfusions

Question 19

It is speculated that acalculous cholecystitis is caused by…

Answer 19

…alterations in fluids & electrolytes & alterations in regional blood flow in the visceral circulation

Question 20

Bile Stasis

Answer 20

Caused by lack of gallbladder contraction

Question 21

Risk Factors for Developing Pigment Stones

Answer 21

Patients w/:
- Cirrhosis
- Hemolysis
- Infections of the biliary tract

Question 22

(True or False) Pigment stones do not usually require surgery, they can can dissolve on their own.

Answer 22

False

Pigment stones CANNOT be dissolved, they need to be removed surgically

Question 23

Modifiable Risk Factors for Biliary Stone Formation

Answer 23

Weight

Consumption of:
- Sugar & sweet foods
- Low-fiber foods
- Fast foods

Question 24

Cholelithiasis Med Management: ERCP (Endoscopic Retrograde Cholangiopancreatography)

Answer 24

Patient MUST be NPO for procedure

IV sedation and anesthesia

Observe for signs of CNS and respiratory depression

Monitor vital signs and signs of perforation or infection

Question 25

Dietary Management of Cholelithiasis

Answer 25

Low-fat liquid diet Advanced diet as tolerated Avoid eating fast food, sweet & sugary foods, & low-fiber foods

Question 26

Med Management of Cholelithiasis: ursodeoxycholic acid and chenodeoxycholic acid

Answer 26

Dissolve stones made of cholesterol Indicated for patients refusing to go to surgery.

Question 27

Med Management of Cholelithiasis: Laparoscopic cholecystectomy

Answer 27

Standard of therapy Performed through a small incision/puncture through abdominal wall Pts do not develop paralytic ileus Pts discharged the same day or w/in 1-2 days Bile duct injury most common complication

Question 28

Assessment of the Patient Undergoing Surgery for Gallbladder Disease

Answer 28

Patient history-smoking, respiratory problems Knowledge and education needs-avoid smoking, aspirin, NSAIDs (bleeding) Respiratory status and risk factors for postoperative respiratory complications Nutritional status-dietary history/lab values Monitor for potential bleeding GI symptoms: after laparoscopic surgery, assess for loss of appetite, vomiting, pain, distention, fever (potential infection or disruption of GI tract)

Question 29

Potential Complications for Patients Undergoing Surgery for Gallbladder Disease

Answer 29

Bleeding GI symptoms related to biliary leak or injury to the bowel Complications related to surgery in general: atelectasis, thrombophlebitis

Question 30

Nursing Diagnoses for Patients Undergoing Surgery for Gallbladder Disease

Answer 30

Acute pain and discomfort Impaired Gas Exchange Impaired Skin Integrity Impaired nutritional status Knowledge defecit

Question 31

Nursing Interventions for Patients Undergoing Surgery for Gallbladder Disease

Answer 31

Place patient in low Fowler's position Manage NG tube or make the patient NPO until bowel sounds return; then a soft, low-fat, high-carbohydrate diet Manage care of biliary drainage system: Note output and drainage color Administer analgesics, pain management Encourage patient to turn, cough, and deep breathe; splinting to reduce pain Promote early ambulation Check puncture site daily for infection, allow adhesive strips to fall off

Question 32

Med Management of Cholelithiasis: Nonsurgical removal

Answer 32

Via instrumentation Intracorporeal/extracorporeal lithotripsy: Stones are fragmented by means of laser pulse therapy

Question 33

Pharmacological Management of Gallstones

Answer 33

Ursodeoxycholic acid (UDCA) & chenodial are used to dissolve small, radiolucent stones composed of cholesterol - Desaturates bile via inhibition of cholesterol secretion & synthesis 6-12 months of therapy is required in many patients to dissolve stones Potential Side Effects: - GI symptoms - Pruritis - Headache

Question 34

Indications for Laparoscopic/ Open Cholecystectomy

Answer 34

Patients w/: - Frequent symptoms - Cystic duct occlusion - Pigment stones

Question 35

Gerontological Considerations for Gallstones

Answer 35

Surgical intervention for diseases of the bile duct tract is more common in older adults Cholesterol saturation of bile increases w/ age - Increased hepatic secretion of bile - Decreased bile acid synthesis May not exhibit typical symptoms (fever, pain, chills, jaundice) - Symptoms may be preceded or accompanied by symptoms of septic shock - Oliguria - Hypotension - Changes in LOC - Tachycardia & tachypnea

Question 36

Pancreas Location

Answer 36

Upper abdomen

Question 37

Pancreas Exocrine Secretions

Answer 37

Amylase, trypsin, lipase, secretin

Question 38

Function of Amylase

Answer 38

Aids in the digestion of carbs

Question 39

Function of Trypsin

Answer 39

Aids in digestion of proteins

Question 40

Function of Lipase

Answer 40

Aids in digestion of fats

Question 41

Pancreas Endocrine Secretions

Answer 41

Insulin, glucagon, somatostatin

Question 42

Function of Insulin

Answer 42

Lowers blood glucose & promotes storage of fat in adipose tissue - Also synthesis of protein in various tissues

Question 43

Function of Glucagon

Answer 43

Main function is to raise blood glucose by converting glycogen into glucose in liver

Question 44

Function of Somatostatin

Answer 44

Exerts a hypoglycemic effect by interfering w/ release of growth hormone from the pituitary & glucagon by the pancreas

Question 45

Gerontological Considerations for Pancreatic Function

Answer 45

People older than 70 y.o.: Increase in fibrous material & fatty deposits w/in the pancreas Decreased rate of pancreatic enzyme secretion & decreased bicarbonate output Impairment of "normal" fat absorption w/ increasing age due to delayed gastric emptying & pancreatic insufficiency Decreased Ca+2 absorption may also occur * These changes require care in interpreting diagnostic results & in providing dietary counseling

Question 46

Pancreatitis

Answer 46

Inflammation of the pancreas Can be acute or chronic

Question 47

Which form of pancreatitis can be more life-threatening: acute or chronic?

Answer 47

Acute can be a medical emergency associated w/ high risk of life-threatening complications & mortality Chronic often goes undetected since classic clinical & diagnostic findings are not always present in the early stages

Question 48

Common Causes of Pancreatitis

Answer 48

Chronic alcohol use Cholelithiasis

Question 49

Main Differences Between Acute & Chronic Pancreatitis

Answer 49

Acute: Can be LIFE-THREATENING! Usually reversible Chronic: Long-term inflammation puts them at risk of malignancy. Progressive destruction of the pancreas

Question 50

Acute Pancreatitis Pathophysiology

Answer 50

Pancreatic duct becomes obstructed, and enzymes back up, causing autodigestion and inflammation of the pancreas

Question 51

Clinical Manifestations of Acute Pancreatitis

Answer 51

Severe abdominal pain is the major symptom that causes the patient to seek medical care - Abdominal pain & tenderness & back pain are due to irritation & edema of the pancreas - Pain occurs in the midepigastrum - Frequently acute in onset: Occurs 24-48 hrs after heavy meal or alcohol ingestion - May be diffuse & difficult to localize Abdominal distension - Poorly defined palpable abdominal mass - Rigid or board-like abdomen may develop (peritonitis) Ecchymosis (bruising) of the flank or around umbilicus-> severe pancreatitis Bowel sounds decreased or absent Low-grade fever, leukocytosis Hypotension, tachycardia Cyanosis, dyspnea Jaundice Abnormal lung sounds - crackles, diminished sounds Discoloration of the abdominal wall - Turner's or Cullen's sign SIGNS OF SHOCK- Vital signs (increased respirations, tachycardia, hypotension)

Question 52

Cullen's Sign

Answer 52

Superficial bruising in the subcutaneous fat around the umbilicus

Question 53

Grey Turner's Sign

Answer 53

An uncommon subcutaneous manifestation of intra-abdominal pathology that manifests as ecchymosis or discoloration of the flanks

Question 54

Which form of acute pancreatitis is more common in patients: interstitial edematous pancreatitis or necrotizing pancreatitis?

Answer 54

Interstitial Edematous Pancreatitis

Question 55

Mild Acute Pancreatitis

Answer 55

AKA Interstitial Edematous Pancreatitis Characterized by lack of pancreatic or peripancreatic parenchymal necrosis w/ diffuse enlargement of the gland due to inflammatory edema Edema & inflammation are self-limited to the pancreas Minor organ dysfunction: Should return to normal function w/in 6 months Acutely ill: Risk for hypovolemic and Septic shock

Question 56

Severe Acute Pancreatitis

Answer 56

AKA Necrotizing Pancreatitis Characterized by tissue necrosis in either the pancreatic parenchyma or in the tissue surrounding the gland Can either be sterile or infected If parenchyma is involved-> marker for more serious disease - Rapidly fatal - More complete enzyme digestion - Local blood vessels damage Local Implications Include: - Pancreatic cysts - Abscesses - Acute fluid collections in or near the pancreas Bleeding & Thrombus Systemic Complications: - Organ Failure (pulmonary insufficiency, hypoxemia) - Kidney disease - GI bleed - Shock

Question 57

Gerontological Considerations for Pancreatitis

Answer 57

Mortality rate increases with age Increased risk of multi-organ dysfunction Aggressive treatment necessary to reduce mortality

Question 58

Acute Pancreatitis Complications

Answer 58

Fluid and electrolyte disturbances: hypocalcemia, hypotension, low UO Necrosis of the pancreas: due to hemorrhage and septic shock Shock: hypovolemia, bacterial infection, and fluid in the peritoneal cavity Multiple organ dysfunction syndromes (MODS) Disseminated intravascular coagulation (DIC)

Question 59

Acute Pancreatitis Diagnostic Findings

Answer 59

Serum amylase (25-125 U/L) - >200 U/L for 24-72 hours - Starts to rise 2-6 hours after onset of pain -Peaks @ 24 hours -Return to normal @ 72 hours Serum lipase (3-19 U/dL): used with amylase; rises later than amylase (48 hours) -Return to normal 8-14 days Increased WBC's > 16, 000 mm3 Increased glucose > 200 mg/dL Increased lipids LDH > 350 IU/L Decreased calcium < 8mg/dL

Question 60

Acute Pancreatitis Med Management

Answer 60

Antibiotics for infection Correction of blood, fluid loss, and low albumin levels. Insulin therapy for critically ill patients Respiratory care because of the hypoxemia Biliary Drainage-reestablish drainage of the pancreas Diagnostic laparotomy -surgery to establish pancreatic drainage D/C thiazide diuretics, corticosteroids, oral contraceptives Low fat and protein diet No alcohol or caffeine

Question 61

Acute Pancreatitis Nursing Management: Relieving pain and discomfort

Answer 61

Assess pain level Administer IV opioid analgesics via PCA pump Place pt in side-lying position Maintain bed rest in acutely ill-decrease metabolic rate Manage NG tube to relieve N/V and oral hygiene to decrease discomfort from NG tube

Question 62

Acute Pancreatitis Nursing Management: Improving Breathing Pattern

Answer 62

Administer Oxygen Elevate HOB, Place in Semi-Fowler's position - Decreases pressure on diaphragm due to distention Position changes to prevent atelectasis and pooling of secretions and pneumonia Monitor for atelectasis, pleural effusions Encourage TCDB, incentive spirometer

Question 63

Acute Pancreatitis Nursing Management: Improving Nutritional Status

Answer 63

Make the pt NPO Admin enteral feedings & parenteral nutrition to decrease secretion of secretin Monitor serum glucose levels q 6hrs

Question 64

Acute Pancreatitis Nursing Management: Maintaining Skin Integrity

Answer 64

Assess wounds & draining site for infection, inflammation, & breakdown Turn pt every 2 hrs Perform wound care as prescribed

Question 65

Acute Pancreatitis Nursing Management: Monitor & Manage Potential Complications

Answer 65

Administer IV fluids and blood products for hypovolemic shock Administer IV calcium gluconate and magnesium sulfate for low magnesium and calcium levels Monitor hemodynamics in ICU for patients with pancreatic necrosis Nursing management in ICU for Shock, DIC, and MODS: -Assist with ventilator management -Monitoring hemodynamics -Prevent additional complications

Question 66

Chronic Pancreatitis Pathophysiolgy

Answer 66

A progressive inflammatory disorder w/the destruction of the pancreas; cells are replaced by fibrous tissue; pressure within the pancreas increases, obstructing the pancreatic and common bile ducts

Question 67

Clinical Manifestations of Chronic Pancreatitis

Answer 67

Abdominal pain: Located in the same areas as in acute pancreatitis -Heavy, gnawing feeling; burning and cramp-like Malabsorption with weight loss Constipation Mild jaundice with dark urine ( "tea-colored") Steatorrhea: fatty, foul-smelling stool Frothy urine/stool Diabetes

Question 68

Chronic Pancreatitis Diagnostic Findings

Answer 68

Lab Tests: Serum amylase/lipase: May be ↑ slightly or not at all ↑ Serum bilirubin ↑ Alkaline phosphatase Mild leukocytosis Elevated sedimentation rate Diagnostics: -ERCP -CT -MRI -Ultrasound

Question 69

Chronic Pancreatitis Goals & Nursing Management

Answer 69

Prevent acute exacerbations Pain relief Control of pancreatic exocrine and endocrine insufficiency -Pancreatic enzyme replacement; bile salts -Acid-neutralizing and acid-inhibiting drugs Low fat, high-carbohydrate diet -Recognize and address effects of malabsorption Avoid crash diets and binging

Question 70

Chronic Pancreatitis: Surgical Treatment

Answer 70

Indicated when biliary disease is present or if obstruction or pseudocyst develops Divert bile flow Ex: Choledochojejunostmy Or relieve ductal obstruction Ex: Sphincterectomy

Question 71

Home/Ambulatory Care for Chronic Pancreatitis

Answer 71

Focus is on chronic care and health promotion Dietary control: -No alcohol -Avoid caffeine -Low fat, high carbohydrate diet -Avoid crash diets and binging Smoking cessation Control of diabetes Taking pancreatic enzymes CORRECTLY Patient and family teaching r/t disease progression

Question 72

The client is being prepped for discharge after laparoscopic cholecystectomy. Which intervention should the nurse implement?

Answer 72

Include the pt's significant other w/discharge teaching

Question 73

A nurse is providing discharge teaching for laparscopic cholecystectomy. Which post-op instructions should be included? A) Take baths rather than showers B) Take off adhesive after 24 hrs C) Continue diet of choice

Question 74

The nurse is caring for a newly admitted client with acute pancreatitis. Which interventions should the nurse implement? A) NS 1000mL IV over 1 hr, then IV fluids at 250 ml/hr B) Initiate NG tube feedings w/ low-fat formula C) Vital signs every shift D) Up to chair for meals & ambulate 4X daily

Question 75

A nurse receives report on 4 assigned clients. Prioritize the order that the nurse should assess the clients. 47 year old client 2 days post-cholecystectomy who has pain rated 2/10 57-year-old w/ possible acute pancreatitis, severe abd pain, low O2 & BP 64-year-old w/ cirrhosis, jaundice, itching, & elevated ammonia level 82 yr old who is unable to void w/ bladder scan showing 300 mL of urine

Answer 75

57-year-old w/ possible acute pancreatitis, severe abd pain, low O2 & BP 64-year-old w/ cirrhosis, jaundice, itching, & elevated ammonia level 82 yr old who is unable to void w/ bladder scan showing 300 mL of urine 47 year old client 2 days post-cholecystectomy who has pain rated 2/10