Pancreas and Gallbladder PDF PDF

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Biliary Module Objectives Module Objectives:!" Utilizing clinical reasoning and the nursing process, the student is expected to:" !1. Analyze comprehensive assessment findings by:!" !!! a. Comparing and contrasting risk factors associated with the following Gastrointestinal disorders: !!"

Gallbladder disorders -Cholelithiasis #

-Refers to formation of calculi (e.g. gallstones) in the gallbladder." -Risk Factors" # -Results from changes in bile!components!or bile stasis, associated with: # # -Infection" # # -Cirrhosis" # # -Pancreatitis" # # -Celiac disease" # # -Diabetes mellitus" # # -Pregnancy" # # -Hormonal contraceptive use"

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-Pathophysiology: " # -Calculi usually from solid constituents of bile; the three major types are:" # # 1. Cholesterol gallstones!– the most common type, thought to form in # # # # supersaturated bile" # # 2. Pigment gallstones!– formed mainly of unconjugated pigments in bile # # precipitate" # # 3. Mixed types!– with characteristics of pigment and cholesterol stones."

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-Assessment/Clinical Manifestations/Signs And Symptoms:" # -Cholelithiasis (up to ½ of persons with gallstones are asymptomatic; however # # # possible clinical manifestations include the following):" # # -Episodic (commonly after a high-fat meal), cramping pain in the right # # # # upper abdominal quadrant or the epigastrium, possibly radiating to the # # # # back near the right scapular tip (i.e. biliary colic)" # # -Nausea and vomiting" # # -Fat intolerance" # # -Fever and leukocystosis" # # -Signs and symptoms of jaundice"

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-Laboratory and diagnostic study findings:" # -Biliary ultrasonography (i.e. cholecystosonography) can detect gallstones in # # most cases"

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-Medical Management" # -Teach the client about planned treatments." # -Chenodeoxycholic acid is administered to dissolve gallstones. It is effective in # # # dissolving about 60% of radiolucent gallstones. Pigment gallstones cannot be # # # dissolves and must be excised."

-Gallstones can obstruct the cystic duct, causing cholecystitsi, or the common # # bile duct, which is called choledocholithiasis."

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-Nonsurgical removal, such as lithotripsy or extracorpeal shock wave therapy, # # may be implemented."

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-Surgical treatment: " # -Laparoscopic cholecytectomy (usually outpatient surgery) is performed # # # through a small incision made through the abdominal wall in the umbilicus." # # -Assess incision sites for infection. Instruct the client to notify the health # # # # care provider if loss of appetite, vomiting, pain, abdominal distention, or # # # # fever occur." # # -Advise the client that he will need assistance at home for 2 to!3 days." # -Cholecystectomy is removal of the gallbladder after ligation of the cystic duct ## # and artery. " # # -Inform the client that a T-tube will be inserted to drain blood; # # # # # serosanguineous fluids, and bile and that the T-tube must be taped # # # # below the incision" # -Choledochostomy is an incision into the common bile duct for calculi removal." # -Cholecystomy is the surgical opening of the gallbladder for removal of stones, ## # bile, or pus, after which a drainage tube is placed."

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-Nursing Diagnosis" # -Acute pain secondary to biliary obstruction" # -Ineffective coping related to nausea" # -Deficient knowledge related to diagnosis" # -Impaired gas exchange related to high abdominal surgical incision." # -Impaired skin integrity related to altered biliary drainage after surgical incision." # -Imbalanced nutrition related to inadequate bile secretion." " -Nursing Management:" # -Provide nursing interventions during an acute gallbladder attack." # -Intervene to relive pain; give prescribed analgesics" # -Promote adequate rest" # -Administer IV fluids, monitor intake and output" # -Monitor nasogastric tube and suctioning" # -Administer antibiotics if prescribed." # -Provide adequate nutrition." # -Assess nutritional status. " # -Encourage a high-protein, high-carbohydrate, low-fat diet."

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-Cholecystitis # -Several disorders affect the biliary system and interfere with normal drainage of # # bile into the duodenum." # -Cholecystitis!is the acute or chronic inflammation of the gallbladder." -Classifications:" # 1. Calculous cholecystitis" # # -In calculous cholecystitis, a gallbladder stone obstructs bile outflow." 2. Acalculous cholecystitis" # # -Acalculous cholecystitis describes acute inflammation in the absence of # # obstruction by!gallstones." -Pathophysiology:" # -Calculous and acalculous cholecystitis have different origins."

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-Statistics and Incidences:" # -Cholecystitis account!for most patients requiring gallbladder!surgery." # -Although not all occurrences of cholecystitis are related cholelithiasis, more # # than!90%!of patients with acute cholecystitis have gallstones." # -The!acute form!is most common during middle age." # -The!chronic form!usually occurs among!elderly!patients."

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-Causes -The causes of cholecystitis include:" # 1. Gallbladder stone!" # # # -Cholecystitis is usually associated with gallstone impacted in the # # # cystic duct." # 2. Bacteria" # # # -Bacteria plays a minor role in cholecystitis; however, # # # # # # secondary!infection!of bile occurs in approximately 50% of cases." # # 3. Alterations in!fluids and electrolytes" # # # -!Acalculous cholecystitis is speculated to be caused by # # # # # # alterations in!fluids and electrolytes." # # 4. Bile stasis" # # # -Bile stasis or the lack of gallbladder contraction also play a role # # # # # in the development of cholecystitis." -Clinical Manifestations -Cholecystitis causes a series of signs and symptoms:" # # -Pain—Right upper quadrant pain occurs with cholecystitis." # # -Leukocytosis—An increase in the WBC occurs because of the body’s # # # # attempt to ward off pathogens." # # -Fever—Fever occurs in response to the infection inside the body." # # -Palpable gallbladder—The gallbladder becomes edematous as ## # # # infection progresses." # # -Sepsis—Infection reaches the bloodstream and the body # # # # # undergoes!sepsis."

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-Complications" # -Cholecystitis can progress to gallbladder complications, such as:" # # 1. Empyema—An empyema of the!bladder!develops if the gallbladder # # # # becomes filled with purulent fluid." # # 2. Gangrene—Gangrene develops because the tissues do not receive # # # # enough oxygen and nourishment at all." # # 3. Cholangitis—The infection progresses as it reaches the bile duct."

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-Assessment and Diagnostic Findings" # -Studies used in the diagnosis of cholecystitis include:" # # 1. Biliary ultrasound:!Reveals calculi, with gallbladder and/or bile duct # # # # distention (frequently the initial!diagnostic procedure)."

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1. Obstruction = Calculous cholecystitis occurs when a gallbladder # stone obstructs the bile outflow." 2. Chemical reaction = Bile remaining in the gallbladder initiates a # chemical reaction; autolysis and edema occur." 3. Compression = Blood!vessels in the gallbladder compressed, ## compromising its vascular supply."

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2. Oral cholecystography (OCG):!Preferred method of visualizing # # general appearance and function of gallbladder, including presence of # # filling defects, structural defects, and/or stone in ducts/biliary tree. " # -Can be done IV (IVC) when!nausea/vomiting!prevent oral intake, ## # when the gallbladder cannot be visualized during OCG, or when # # # symptoms persist following cholecystectomy." # - IVC may also be done perioperatively to assess structure and # # # function of ducts, detect remaining stones after lithotripsy or # # # cholecystectomy, and/or to detect surgical complications. " # -Dye can also be injected via T-tube drain postoperatively."

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3. Endoscopic retrograde cholangiopancreatography (ERCP):!Visualizes biliary tree by cannulation of the common bile duct # through the duodenum." 4. Percutaneous transhepatic cholangiography (PTC):!Fluoroscopic # imaging distinguishes between gallbladder disease and!cancer!of the # pancreas (when jaundice is present); supports the diagnosis of # # obstructive jaundice and reveals calculi in ducts."

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5. Cholecystograms (for chronic cholecystitis):!Reveals stones in the # # biliary system.!" # -Note:Contraindicated in acute cholecystitis because # # # # patient is too ill to take the dye by mouth."

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6. Nonnuclear!CT scan:!May reveal gallbladder cysts, dilation of bile # ducts, and distinguish between obstructive/nonobstructive jaundice."

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7. Hepatobiliary (HIDA, PIPIDA) scan:!May be done to confirm # # # diagnosis of cholecystitis, especially when barium studies are # # # contraindicated. Scan may be combined with cholecystokinin injection to demonstrate abnormal gallbladder ejection."

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8. Abdominal x-ray films (multipositional):!Radiopaque (calcified) # gallstones present in 10%–15% of cases; calcification of the wall or # enlargement of the gallbladder."

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9. Chest x-ray:!Rule out respiratory causes of referred pain."

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10. CBC:!Moderate leukocytosis (acute)."

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11. Serum bilirubin and amylase:!Elevated."

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12. Serum liver enzymes—AST; ALT; ALP; LDH:!Slight elevation; # # alkaline phosphatase and 5-nucleotidase are markedly elevated in biliary # obstruction."

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13. Prothrombin levels:!Reduced when obstruction to the flow of bile # # into the intestine decreases absorption of vitamin K."

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14. Ultrasonography.!Ultrasound is the preferred initial imaging test for # # the diagnosis of acute cholecystitis; scintigraphy is the preferred # # # alternative."

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15. CT scan.!CT scan is a secondary imaging test that can identify extra-# biliary disorders and acute complications of cholecystitis."

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16. MRI.!Magnetic resonance imaging is also a possible secondary # choice for confirming a diagnosis of acute cholecystitis."

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17. Oral cholecystography.!Preferred method of visualizing general # appearance and function of the gallbladder."

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18. Cholecystogram.!Cholecystography reveals stones in the biliary # system."

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19. Abdominal xray.!Radiopaque or calcified gallstones present in 10% ## to 15% of cases."

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-Medical Management: " # -Management may involve controlling the signs and symptoms and the # # # # inflammation of the gallbladder." # # 1. Fasting.!The patient may not be allowed to drink or eat at first in order # # to take the stress off the inflamed gallbladder; IV fluids are prescribed to ## # # provide temporary food for the cells." # # 2. Supportive medical care.!This may include restoration # # # # # of!hemodynamic stability!and antibiotic coverage for gram-negative # # # # enteric flora." # # 3. Gallbladder stimulation.!Daily stimulation of gallbladder contraction # # # # with!IV cholecystokinin!may help prevent the formation of gallbladder # # # # sludge in patients receiving!TPN."

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-Pharmacologic Therapy:" # -The following medications may be useful in patients with cholecystitis:" # # 1. Antibiotic therapy." # # # - Levofloxacin!and!Metronidazole!for prophylactic antibiotic # # # # # coverage against the most common organisms." # # 2. Promethazine!or!Prochlorperazine!may control nausea and prevent # # # # fluid and electrolyte disorders." # # 3. Oxycodone!or!Acetaminophen!may control inflammatory signs and # # # # symptoms and reduce pain."

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-Surgical Management:" # -Because cholecystitis frequently recurs, most people with the condition ## # # eventually require gallbladder removal." # -Cholecystectomy:" # # -Cholecystectomy is most commonly performed by using a laparoscope ## # # and removing the gallbladder." # -Endoscopic retrograde cholangiopancreatography (ERCP):" # # -ERCP visualizes the biliary tree by cannulation of the common bile duct ## # # through the duodenum."

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-Nursing Management: " # -Management of cholecystitis include the following:" # # 1. Nursing Assessment:"

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# # # -Integumentary system." # # # # -!Assess skin and mucous membranes." # # # -Circulatory system:!" # # # # -Assess peripheral pulses and capillary refill." # # # -Bleeding:" # # # # -!Assess for unusual bleeding: oozing from injection # # # # # # sites, epistaxis, bleeding gums, petechiae, ecchymosis, # # # # # # hematemesis, or melena." # # # -Gastrointestinal system:!" # # # # -Assess for abdominal distension, # # # # # # # # # frequent belching, guarding, and reluctance to move." " " -Nursing Diagnosis: " # -Based on the assessment data, the major nursing diagnosis for the patient may # include:" # # 1. Acute pain!related to the inflammatory process." # # 2. Risk for!imbalanced nutrition!related to self-imposed dietary # # # # # restrictions and pain."

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-Nursing Care Planning!& Goals:" # -4 Cholecystitis and Cholelithiasis Nursing Care Plans:" # -The major goals for the patient include:" # # -Relieve pain and promote rest." # # -Maintain fluid and electrolyte balance." # # -Prevent complications." # # -Provide information about disease process, prognosis, and treatment # # # # needs."

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-Nursing Interventions:" # -Treatment of cholecystitis depends on the severity of the condition and the # # presence or absence of complications."

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1. Pain assessment:" # -!Observe and document location, severity (0-10 scale), and character of # # pain." 2. Activity:!" # -Promote bedrest, allowing the patient to assume a position of comfort."

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3. Diversion:" # -!Encourage use of!relaxation!techniques, and provide diversional # # # activities." 4. Communication:" # -Make time to!listen!and to maintain frequent contact with the patient." 5. Calories:" # -Calculate caloric intake to identify nutritional deficiencies or needs." 6. Food planning:" # -Consult the patient about likes and dislikes, foods that cause distress, # # # and preferred meal schedules." 7. Promote appetite:" # -Provide a pleasant atmosphere at mealtime and remove noxious stimuli." 8. Laboratory studies: !"

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# # -Monitor laboratory studies: BUN, pre-albumin, albumin, total protein, # # # transferrin levels." " -Evaluation:" # -Expected patient outcomes are:" # # 1. Pain relieved." # # 2. Homeostasis achieved." # # 3. Complications prevented/minimized." # # 4. Disease process, prognosis, and therapeutic regimen understood."

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" -Discharge and Home Care Guidelines:" # -The focus of discharge instructions for patients with cholecystitis is education."

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-Documentation Guidelines" # -The focus of documentation should include:" # # 1. Client’s description of response to pain." # # 2. Specifics of pain inventory." # # 3. Expectations of pain management." # # 4. Acceptable level of pain." # # 5. Prior!medication!use." # # 6. Caloric intake." # # 7. Individual cultural or religious restrictions, personal preferences." # # 8. Availability and use of resources." # # 9. Plan of care." # # 10. Teaching plan." # # 11. Response to interventions, teaching, and actions performed." # # 12. Attainment or progress toward desired outcomes." # # 13. Modifications to plan of care."

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-Education:" # -Patients with cholecystitis must be educated regarding causes of their # # # disease, complications if left untreated, and medical and surgical ## # # options." -Activity:!" # -Ambulate and increase activity as tolerated." -Diet:!" # -Consult with the dietitian or nutritional support to establish individual # # # nutritional needs."

-Pancreatitis -Fx on the pancreas is to release proteolytic enzymes that assist in the breaking ## # down food products (proteins) so that nutrients can be absorbed -Etiology and pathophysiology:" # # 1. Pancreatic ducts become obstructed" # # 2. Hypersecretion of the exocrine enzymes pf pancreas" # # 3. These enzymes enter the bile duct, where they are active with bile back up # # # into the pancreatic duct" # # 4. Pancreatitis and auto-digestion " # # " # -Trypsinogen—(a proteolytic enzyme)" # # -Normally released into the small intestine, where it is activated to trypsin"

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-In AP, activated to trypsin in the pancreas causing auto-digestion of pancreas"

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-Progression of disease" # -Auto digestion" # -Acute inflammation of pancreas" # -Necrosis of pancreas" # -Digestion of vascular walls" # -Thrombus and hemorrhage" # -Shock and death"

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-Clinical Manifestations:" # -Acute Pancreatitis: -CAN BE A MEDICAL EMERGENCY ASSOCIATED WITH A RISK FOR # # # # LIFE-THREATENING COMPLICATIONS" # # -Cyanosis, dyspnea, flushing" # # -Bowel sounds decreased or absent" # # -Low grade fever. leukocytosis" # # -Hypotension, tachycardia" # # -Jaundice" # # -Abnormal lung sounds-crackles " # # -Discoloration of the abdominal wall" # # -SIGNS OF SHOCK# # " -Treatments: -Prevent infection" # # -Enteral nutrition" # # -Antibiotics" # # -Endoscoptically or CT-guided percutaneous aspiration " # -Fluid and electrolyte replacements" # # -Assess for hypocalcemia" # # -Decreased chloride, K+, Na+ due to frequent vomiting and suctioning" # # -IV fluids NS and LR" # # -Blood, plasma expanders, Albumin" # -Antacids, H2 receptor antagonists" # -Vasoactive drugs: dopamine (Intropin)" # -Analgesic: Morphine or Dilaudid" # -Antispasmodic agent" # -Spasmolytics—Nitroglycerine" # -Positioning—sitting up and leaning forward or side-lying; Rest—knees flexed" # -N/V: Ondansetron (Zofran)" # -NPO" # -NG suction" # -Assess labs: CBC, BMP, LFT, Amylase, Lipase, INR" # -Trend vital signs" # # -Cardiac monitoring " # -Dietary teaching:# # " # # -High car low fat diet" # # -Avoid alcohol and smoking cessation# " # -Patient/family teaching:" # # -Signs of infection, high blood glucose, steatorrhea" # # -Rest and regain strength" -Surgical therapy:" # -ECRP"

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# -Endoscopic sphincterotomy" # -Laparoscopic c...