View
234
Download
2
Category
Preview:
Citation preview
1
Liver, biliary, and pancreatic needs
Therapeutic nursing interventions
NSG 4037 Adult Nursing III2007
Liver, pancreas, biliary system
Normal Pancreas Disorders of the exocrine pancreasAcute pancreatitis
Inflammation of the pancreasAutodigestion of pancreasFat necrosis Hemorrhage
Acute pancreatitis Pancreatitis
2
Pancreatitis Disorders of the exocrine pancreasRisk factors of Acute pancreatitis
Alcohol abuse-major causeCholelithiasisAbdominal trauma
Disorders of the exocrine pancreasEtiology of Acute pancreatitis
Exact cause unknownProteins may plug the small pancreatic ductules.HyperlipidemiaHypercalcemiaPancreatic traumaPancreatic ischemiaDrugs ( antibiotics, anticonvulsants, thiazides, sulfonamides, valproic acid, diuretics)
Disorders of the exocrine pancreasPathophysiology of pancreatitis
When protease and lipase are activated before secreted into the intestine then pancreatic tissue damage occursOnce inflammation begins, a vicious circle of further tissue damage continues.
Disorders of the exocrine pancreasClinical manifestations of A.pancreatitis
Mild, nonspecific abdominal pain progressing to severe pain Local peritonitisPain in mid-epigastrium radiating to back as well as the chest, flanks, and lower abdomenNausea & vomiting due to pain
Disorders of the exocrine pancreasTypical features of client w/ pancreatitis
Distressed, anxiousAbdominal distention and tendernessFever r/t paralytic ileus Turners sign- bluish discoloration of left flankCullen’s sign- bluish discoloration of the periumbilical areaJaundice-uncommon
3
Disorders of exocrine pancreasSevere circulatory complications in A. pancreatitis
Hypotension, pallor, cool, clammy skin,hypovolemia
Disorders of the exocrine pancreasOther findings
Cerebral abnormalities, belligerence, confusion, psychosis, and comaTransient hyperglycemia and diabetes may developHigh serum amylase and lipaseChest films show left atelectasis, left pleural effusion, elevated left hemidiaphragmAbdominal films show air in duodenal loop, distention of the colon, gallstones
Disorders of the exocrine pancreasMedical management of A.pancreatitis
Reduce painMaintain volume status, electrolyte balance, and nutritionMaintain pancreatic restTreat complicationsOther measures
Disorders of the exocrine pancreasNursing management
Assess and manage painUse non pharmacologic measures for pain reliefKeep NPO and provide oral hygieneMonitor vital signs for hemodynamic changesMonitor urine outputMonitor respirations and breath soundsMonitor anxiety
Disorders of the exocrine pancreasSurgical management
Indicated in uncertainty of diagnosisTreatment of secondary pancreatic infections, necrosis or abscessCorrection of associated biliary tract diseaseProgressive deterioration despite optimal supportive care
Disorders of the exocrine pancreasPostoperative nursing management
Understand the procedure that was performedKnow location and purpose of all drainsContinually assess tubes and drains.If T tube becomes nonfunctional alert the MD ASAP.
4
Disorders of the exocrine pancreasDischarge planning
Verbalize disease process and how to prevent recurrenceDiscuss medication regimenDiet modificationManifestations of recurrence
Disorders of the exocrine pancreasChronic pancreatitis
Progressive fibrosis and degeneration of pancreasDestruction occurs by repeated attacks of pancreatitisDamage is irreversible involving both endocrine and exocrine functions
Disorders of the exocrine pancreasClinical manifestations
Pain may be continuous, intermittent VomitingConstipationFever Jaundice Abdominal distentionFoul, fatty stoolsdiabetes
Icteric sclera
Disorders of the exocrine pancreas
Pancreatic pseudocystsLocalized collections of pancreatic secretions in a cystic structure usually adjacent to the pancreasClinical picture is abdominal pain, early satiety N & V.
Disorders of the exocrine pancreasPancreatic cancer
Fourth common cause of death from cancer90% die within first yearLinked to diabetes mellitus, alcohol use smoking, high fat diet, obesity
5
Pancreatic cancer Disorders of the exocrine pancreasPancreatic cancer
Medical treatment- radiation therapyChemotherapySurgical management- Whipple’s procedure
Disorders of the exocrine pancreasPancreatic trauma
RareHigh morbidity, mortalityInjuries to surrounding tissues likely
Disorders of the exocrine pancreasCystic fibrosis
Hereditary, chronic diseaseAutosomal recessiveChildhood disease but many people are surviving into adulthoodMalabsorption of lipids due to decrease lipase formation
Bile Ducts Bile flow
6
Biliary ducts
Ampulla of Vater
Sphincter of Oddi
Biliary tract disordersCholelithiasis ( gallstones)
Cholecystitis- inflammation of gall bladderInfections TumorsCongenital malformations
CholelithiasisCholesterol Gallstones (cholelithiasis)
Biliary tract disorders-risk factorsCholelithiasis - gallstones
Increasing ageWomen more than menDiabetes mellitusObesity Crohn’s diseaseCirrhosis
Biliary tract disordersGallstones are crystalline structures formed by hardening and adhering of bile constituents.
Gallstones
7
Gangrenous gallbladderand stones Biliary tract disorders
Gallstone formation involves several factors
Bile must become supersaturated with cholesterol or calciumSolute must precipitate from solution as solid crystalsCrystals must come together and fuse to form stones
Biliary tract disordersClinical manifestations
Similar to other disordersMost specific and characteristic is pain or biliary colic.Starts in the upper midline areaRadiate to the back and right shoulder blade.Nausea and vomiting may occur
Biliary tract disordersChronic cholecystitis
Angina pectorisChronic pancreatitisEsophagitisHiatal herniaPeptic ulcerPyelonephritisSpastic colitis
Acute CholecystitisAcute appendicitisAcute hepatitisAcute myocardial infarctAcute pancreatitisAcute pyelonephritisPerforated ulcerPleurisyRight lower lobe pneumonia
Biliary tract disordersClinical manifestations
Restless, trying to get comfortableMay persist few hours or daysIf common bile duct blocked, jaundice and pancreatitis will occurAssessment is very important as biliary colic and coronary artery disease symptoms are remarkably similar
Biliary tract disordersConfirming diagnosis
Abdominal ultrasound is test of choiceERCP can also detect stones in the common bile duct as well as tumors, strictures.
8
Biliary disordersStone extraction
Biliary tract disordersMedical management
Reduce painMonitor fluid and electrolytesEndoscopyGallstone dissolutionExtracorporeal shock wave lithotripsyMonitor for complications
Biliary tract disorders Nursing management
Assess and manage painComfort measures
Insert NG tube if orderedAdminister IV fluids
Assess lab values
Observe for injury post procedure
Biliary tract disordersSelf-care
The client will need to learn about diet changes, drugs, ways to prevent recurrence
Biliary tract disordersSurgical management
Lap cholecystectomyContraindications- stones present in common bile ductComplications- damage to biliary tract, hemorrhage. Lap chole. carries a two fold increase in risk of complications compared to open.
Biliary tract disordersCholecystectomy
Open procedure- removal of gallbladder through abdominal incisionT-tube placed in common duct after removing stones. Drains bile while duct is healingMonitor respiratory status closelyAssess CV statusMonitor pain frequently.
9
Biliary tract disordersAcute cholecystitis
Acute inflammation of gallbladder wall90% due to stone in gallbladder and obstruction of cystic duct5% of cases no stones found Due to obesity and sedentary lifestyle
Biliary tract disordersAcute cholecystitis
Similar to chronic but pain lasts longerN & VLow grade feverMild jaundice in some casesRUQ tenderness and leukocytosisMurphy’s sign
Biliary tract disordersNursing management
Assessment is critical because several other disease processes produce the same manifestations.These patients will receive antibiotics.
Biliary tract disordersChronic Cholecystitis
Sometimes occurs following acute episodeCan occur independentlyPain is less severeLeukocyte count is higherUsually repeated attacks
Biliary tract disordersCholedocholithiasis
Stones in the common ductCan occur in the absence of a gallbladder
Cholangitis Inflammation of bile ductLab tests- wbc elevated
Bilirubin and alk. phosphatase-elevatedAmylase- check to determine pancreatitis
Biliary tract disordersSclerosing cholangitis
Inflammatory disease of bile ducts that cause fibrosis and thickening of walls and stricturesImportant complications of AIDS.
10
Biliary tract disordersCarcinoma of gallbladder
5% of all cancers but most common of biliary tract70% of patients have gallstonesUnrelenting RUQ pain, weight loss, jaundice and palpable mass (RUQ)Prognosis poor
Hepatic disordersThe liver
Central role in many essential physiologic processesLipid synthesis, detoxifies endogenous and exogenous substances
Hepatic disordersJaundice (icterus)
Yellow pigmentation of the sclerae, skin and deeper tissues caused by the excessive accumulation of bile pigments in the blood.
Common manifestation in many liver and biliary disorders
Hepatic disordersUnconjungated hyperbilirubinemia
Result from overproduction of bilirubin as a result of hemolysis
Conjugated hyperbilirubinemia- impaired excretion of bilirubin from the liver resulting from hepatocellular disease, drugs, sepsis, hereditary disorders or extrahepatic biliary obstruction.
11
Hepatic disordersClinical manifestations
Yellow sclerae,yellowish orange skin, clay-colored feces, tea-colored urine, pruritis, fatigue, and anorexia.
Medical managementDetermine cause, reduce pruritus and maintain skin integrity
Jaundice
Hepatic disordersNursing management
Observe for jaundice, assess taste, and assess pruritusAdminister oral antihistamines as ordered, cholestyramines (Questran), frequent application of lotionSoft bed linen, keep room cool
Hepatic DisordersDisturbed body image
Reassure client that the discoloration is usually temporary, encourage personal hygieneExplain about jaundice, and how long it will last
Hepatic disordersHepatitis
Inflammation of liverCaused by viruses, toxins, or chemicalsViral hepatitisToxic hepatitisChronicAlcoholic
Viral HepatitisViral hepatitis
Occurs worldwideMost common blood borne infection in US and most of worldMost common types-Hepatitis A, B, C,D,and E Hepatitis F and G not considered serious health threats
12
Viral Hepatitis transmissionHepatitis A- infectious hepatitis
Caused by infected water, milk, and foodEspecially raw shellfish from contaminated waters
Hepatitis B-Contact with serum of an infected person is the major mode of transmission. Other body fluids can also transmit.
Viral Hepatitis transmissionHepatitis C- drug use 60% of cases
Tattoing or body piercing can allow transmissionParenterally transmitted like Hep.B
Hepatitis D transmitted through bloodHepatitis E- rare in US. Short incubation and does not become chronic
Viral HepatitisPrevention
Strict hand-washing after bowel movements is requiredStrict hand-washing after contact with contaminated utensils, bedding, clothing.Clients with HBV and HCV should not share razors, toothbrushes, cigarettes or other personal items
Viral hepatitisHepatitis A- vaccine available
Household contacts of persons with HAV should be given immune globulin to prevent spread. Inactivated vaccine should be given to persons traveling to endemic areas and also those with risk factors.
Viral hepatitisHepatitis B
HBV-for active immunity, 3 IM injections given at 0, 1, and 6 months.
Hepatitis CTransmission and prevention similar to HBV
Treated with interferon injections
Viral hepatitisHepatitis D
Hepatitis D must coexist with HBV, the vaccine for HBV helps to prevent HDV
Hepatitis E,F and GHygiene precautions are necessary for prevention of E. No vaccines as yet+-
13
Viral HepatitisPathophysiology
Inflammation of the liver with areas of necrosis occur and the damage leads to function impairment
Clinical manifestationsEarly-jaundice, lethargy, irritability, pruritis,myalgia, anorexia, n &v, abd. pain, diarrhea or constipation, fever, flu-like manifestations
Viral hepatitisIrritability and drowsiness are signs of hepatic encephalopathy when severeDeterioration of handwriting is an early sign of hepatic encephalopathy.
Viral hepatitisLiver is larger and is tender to palpation
Bleeding tendencies due to reduced absorption of vitamin K.
Viral HepatitisPrognosis
8-10 weeks liver function tests return to normal
Viral HepatitisMedical management
Reduce fatigueMaintain fluid and nutritional balanceReduce effects of hepatitisMedications to avoid- chlorpromazine, aspirin, acetaminophen, and sedatives.
Viral HepatitisNursing management
Manage fatigue- encourage rest but also encourage some activity to diminish muscle loss due to bedrest. Bed exercises.Modify diet- encourage breakfast, avoid fatty foods, optimum protein, multiple small meals.Avoid alcoholProvide vitamin supplementsRelieve N & VRelieve anxiety
14
Viral hepatitisComplications of hepatitis
Typically recover completely from the illness in 3-16 weeks. Clients with HBV tend to experience more complications, could lead to destruction of liverCirrhoses or chronic active hepatitis could result
Hepatic disordersChronic hepatitis
Liver inflammation continues beyond a period of 3-6 monthsChronic hep B follows acute in 5% of casesChronic hep C follows in 70% of case
Hepatic disordersToxic hepatitis
Most commonly, the causative agent is a toxic metabolite formed by the drug-metabolizing enzymes within the liverLiver necrosis occurs within 2-3 days after acute exposure to a dose-related hepatotoxin
Hepatic disordersAlcoholic hepatitis
Acute or chronicMost frequent cause of cirrhosisAnorexia, nausea, abdominal pain, hepatomegaly, spleenomegaly, jaundice, ascites, fever, and elevated bilirubinLiver biopsy reveals fatty hepatic tissue
Hepatic disordersCirrhosis
Chronic, progressive disease characterized by widespread fibrosis and nodule formation.Normal flow of blood, bile is altered by fibrosis
Cirrhosis Four major types
AlcoholicPostnecrotic- toxin inducedBiliaryCardiac
15
A close up view of micronodularcirrhosis in a liver with fatty
changes
Cirrhosis Etiology and risk factors
Excessive alcohol ingestionGenetic predisposition Biliary cirrhosisUse of drugs (acetaminophen, methotrexate, isoniazid)Nutritional deficits r/t jejunal bypassHepatic congestion from R-sided heart failure
Cirrhosis Pathophysiology
Nodular consistency with bands of fibrosisAlters flow of bile and blood thru liverPortal vein hypertension
Cirrhosis
Medical managementMonitor for complications
Ascites, bleeding esophageal varices, renal failure, hepatic encephalopathy
Maximize liver functionA nutritious diet with adequate calories and proteinRestrict sodium and fluids in ascitesAdequate rest
Treat underlying causePrevent infection
Cirrhosis Nursing management
Assess for early signs- liver enlargement and lab dataAssess psychosocial status to guide planningMonitor for hemorrhagePrevent hemorrhage- falls, abrasionsProvide client teachingMonitor diet and provide teaching
16
Cirrhosis Complications of cirrhosis
Portal hypertensionPortal vein is likely to be obstructed by a thrombus or a tumorAltered blood flow in liver is responsible for portal hypertensionCirrhosis is most common causeRight-sided heart failure
Cirrhosis Portal hypertension
Manifestations- tortuous epigastric vessels that branch off the umbilicus and lead toward the sternum and ribs.Enlarged palpable spleen, internal hemorrhoids, bruits, and ascites
Cirrhosis Portal hypertension
Medical managementPreventing/controlling hemorrhage esp. in esophageal varices and spleen
Sclerotherapy- sclerosing agent flows into varicesTransjugular intrahepatic portosystemic shuntVasopressin in light of variceal bleedingBalloon tamponade
Portal hypertensionSurgical management
Endoscopic band ligationPortosystemic shunt
Figure 1 Rubber band (arrow) placed over a varix
Garcia-Pagán JC and Bosch J (2005) Endoscopic band ligation in the treatment of portal hypertensionNat Clin Pract Gastroenterol Hepatol 2: 526–535 doi:10.1038/ncpgasthep0323
This figure is provided courtesy of Dr J Llach.
Portal hypertensionTIPS- shunt
17
Sengstaken-Blakemore tube Cirrhosis Nursing management
Assess for presence of hemorrhageTeach patient to reduce risk
Avoid strainingAvoid rough foodsDevelop emergency plan in case of rupture
List of all emergency numbers ready and discuss plan with family members
Cirrhosis Monitor for hemorrhage
Assess vital signs, urine output, assess with restoration of circulating blood volume
Prevent esophageal necrosisPrevent aspiration pneumoniaPrevent nares erosionPrevent airway obstructionMonitor level of consciousnessProtect from injury
Cirrhosis Ascites
With increase in portal pressure, plasma leaks directly from the liver capsule and the congested portal vein into the peritoneal cavity.Liver’s ability to synthesize albumin leads to low levels in blood and then leakage of protein into the peritoneal cavity. This decreases the osmotic pressure and secretion of aldosteronestimulates the kidneys to retain sodium and water. Thus increasing ascitic fluid
Cirrhosis Ascites
Abdominal distention, bulging flanks, and downward protruding umbilicusTests to confirm- paracentesis, abdominal xrays, ultrasound and CT scan
Cirrhosis Ascites
Medical managementCorrect fluid and electrolyte imbalanceParacentesisAlbuminDiet modificationsPromote effective breathing patternsMaintain skin integrity
18
Cirrhosis Nursing management
Percussion of abdomen-dull with ascitesMeasurement of girthAssess for ascitesAssess distress caused by ascitesRestrict fluidsMonitor intake and outputAdminister albumin and diureticsAvoid hepatotoxinsMonitor after paracentesis
Cirrhosis Hepatic encephalopathy
Liver cannot metabolize ammoniaAmmonia is CNS depressantReduced mental alertness, confusion and restlessness.Loss of consciousness, seizures, and irreversible coma in terminal stage
Cirrhosis Hepatic encephalopathy
Medical managementID and treat precipitating causes.Reduce ammonia in blood and bacteria in colonMaintain fluid volume balance
Cirrhosis Nursing management
Evaluate psychophysiologic statusEncourage bowel cleansing Assess fluid volume statusComplications of immobility
Fatty liver (hepatic stenosis)Lipid infiltration- metabolic diseaseCauses
Chronic alcoholismProtein malnutrition in early lifeDiabetes mellitusObesityJejunileal bypassChronic illness that impairs nutritionReye’s syndrome in children
Fatty liverManifestations
Moderate to severe infiltration- asymptomaticMassive infiltration- anorexia, abdominal pain, and sometimes jaundiceFat embolism can occur and cause death
19
Fatty liver Fatty liverNursing interventions
Help direct patients to correct causePrepare for diagnostic proceduresGiving emotional supportGiving supportive physical careDesigning teaching guidelines that promote proper diet and prevent recurrence
Liver neoplasmsPrimary Metastatic
Arise from lungs, GI tract, and breasts
Benign hepatic tumorsFound in women 20-30 y/oAssociated with oral contraceptive useRisk for rupture and hemorrhageDiagnosed with CT scan, USMay be surgically excised
Malignant hepatic tumorsPrimary hepatocellular cancer
Rising due to high prevalence of hepatitis CCirrhosisChronic liver diseaseAnabolic steroid use
Metastatic hepatic cancersCommon site for metastasis
High rate of blood flowSpread by direct extension from adjacent organsVia hepatic arterial systemVia portal venous system
20
Metastatic liver disease Metastatic hepatic cancersClinical manifestations
Early indicators-vagueOnly specific to primary tumorAnorexia, diaphoresis, fever, weight loss, weaknessActive liver disease, such as abdominal pain, ascites, and hepatomegalyElevated serum alkaline phosphataseAbnormal US, CT, MRI
Metastatic hepatic cancerMedical management
Relief of manifestations and promote palliationChemotherapyRadiation therapyBiliary drainage
Metastatic hepatic cancerNursing management
Assess for metabolic malfunctions, pain, bleeding, ascites, edemaPrepare client for diagnostic testingOffer support for them to cope with uncertainty and fear
Liver transplantationSurgical management
Indications-severe, irreversible liver diseasePrimary and secondary biliary cirrhosisHepatitis-chronic with cirrhosisPrimary sclerosing cholangitisBiliary atresia (pediatric)Confined hepatic malignancyWilson’s diseaseAlcoholic cirrhosis
Liver transplantationNursing management
Postop care is to monitor for rejection, infection, and occlusion of vesselsImmunosuppressive therapyConstant monitoring of respiratory, cardiovascular, neurologic and hemodynamic status
21
Liver abscessLocalized collection of pus and organisms within the parenchyma of liverDevelops for 3 reasons
Bacterial cholangitisPortal vein bacteremiaAmebiasis
Rare disordersHematochromatosis-disorder of iron metabolism
Amyloidosis- a proteinaceous, starch-like substance that can infiltrate the liver and other organs.
Congenital conditionsWilson’s disease- related to copper accumulation in tissues of the liver, brain, and kidney. May be fatal
Caroli’s syndrome- dilated bile ducts and cyst formations
Congenital hepatic fibrosis- portal hypertension from portal vein fibrosis
Liver traumaPenetrating injury or blunt traumaEither cause hemorrhageControl hemorrhage
Recommended