Adult Health Nursing II Block 7.0

Adult Health Nursing IIBlock 7.0

TheHepatobiliarySystem

Block 7.0 Module 5.11

I. Cholecystitis --Acute & Chronic --Cholecystectomy --T-Tubes

II. Cancer of Gallbladder

III. Pancreatitis --Acute & Chronic

IV. Pancreatic Cancer

V. Liver Disease --Cirrhosis --Liver Cancer

Diagnostic Tests

Nursing Assessment

Nursing CarePlanning& Evaluation


Learning Outcomes Discuss anatomy and physiology of the

hepatobiliary system Distinguish pathophysiology of hepatobiliary

disorders Discuss clinical manifestations in clients with

hepatobiliary disorders Interpret laboratory findings and diagnostic

testing for clients with hepatobiliary disorders Differentiate interventions and treatment

options for clients with hepatobiliary disorders


Learning Outcomes Discuss medication management of clients

with hepatobiliary disorders Discuss complications associated with

hepatobiliary disorders Prioritize nursing care for clients with

hepatobiliary disorders Explore teaching plans for clients with

hepatobiliary disorders Differentiate hepatobiliary disorders in the

older adult


Quick A & P Overview


The Biliary System Comprised of Liver, Gallbladder, and

Pancreas

Primary Functions:Secrete enzymes and other substances to promote food digestion

Failure of these organs results in impaired digestion which may result in inadequate nutrition


Gallbladder Disorders Function of the Gallbladder:

--Collects, concentrates, and stores bile--Releases bile into duodenum when fat is present

Cholecystitis- Acute and Chronic Cancer of the Gallbladder


Gallbladder


Cholecystitis Inflammation of the Gallbladder May be acute or chronic Acute Cholecystitis

* 2 Types (Calculous & Acalculous)

A. Calculous-

Chemical Irritation and inflammation resulting from gallstones (cholelithiasis) that obstruct the cystic duct, gallbladder neck, or common bile duct. Exact pathophysiology of gallstones is unknown but cholesterol, bilirubin, calcium, and bile salts play a role in their formation


Cholecystitis Acute Cholecytitis B. Acalculous- Inflammation occurring

without gallstones.

Biliary stasis due to any condition that affects filling or emptying of the

gallbladder


Cholecystitis Chronic Cholecysitis Repeated episodes of cystic obstruction Calculi are most always present Gallbladder becomes fibrotic and

contracted resulting in decrease motility and deficient absorption


Cholelithiasis (Gallstones)

Clinical ManifestationsAcute

Sharp pain in right upper quad

Pain with deep inspiration during right subcostal palpation (Murphy’s Sign)

Rebound Tenderness (Blumberg’s Sign)

Nausea, vomiting Loss of appetite Fever Eructation, Flatulence

Chronic Jaundice- Yellow

discoloration of the skin and mucous membranes due to increased bilirubin in the blood

Icterus-Yellow discoloration of the sclera

Pruritis- Accumulation of bile salts due to blockage of bile to the duodenum

Clay colored stools Steatorrhea- (Fatty

Stools)Block 7.0 Module 5.1


Jaundice


Diagnostics RUQ Ultrasound- Most diagnostic test Abdominal X-Rays Hepatobiliary Scans Labs: Check your ATI Book

Elevated WBC Elevated Direct, Indirect, and Total Bilirubin Elevated AST (with liver dysfunction) Elevated LDH (with liver dysfunction) Elevated Serum Cholesterol


Nursing Interventions and Care

HistoryDietary Counseling - Low fat diet

- Promote weight reduction - Avoid gas-forming foods - Small , frequent meals

Pain Management – Meperidine (Demerol)AntispasmodicsAntiemeticsPrepare for Pre and Post-Op Care


Cholecystectomy

Removal of the Gallbladder

Nursing Care: Pain Management Encourage Splinting to reduce pain Fundamentals- turn, cough, deep breathe Monitor incision site Monitor and record T-Tube drainage-initially

bloody then turns to green/brown bile Assess appetite and response to food

Cholecystectomy


T-Tube Ensures patency of common bile duct Limits fluid accumulation allowing duct

to heal

Surgically placed Remains up to 6 weeks post-op

Nursing Care of a T-Tube- Iggy pg. 1370, Chart 62-2



The Older Adult May have Diabetes and have atypical

presentation of symptoms (absence of pain or fever)

Post Op period is of greater risk May have difficulty managing care of T-

Tube at home May have difficulty modifying lifelong

dietary patterns

Cancer of the Gallbladder

Rare, more common in women than menMore common in American Indians

(etiology unknown)

Most cancers are adenocarcinoma and squamous cell

Begin in inner layer of gallbladder (mucosa) and metastasize to outer organs: Liver, small intestine, and pancreas

Prognosis is poor due to late diagnosisBlock 7.0 Module 5.1

Cancer of the GallbladderClinical Manifestations Similar to cholecystitis Anorexia, wt loss Nausea, vomiting Abdominal Bloating Fever Malaise Jaundice- Advanced Enlarged liver and

spleen Severe abdominal

pain-advanced

Treatment Surgery Radiation Chemotherapy



Pancreas Functions: Exocrine: secrete enzymes for digestion

Endocrine: Islets of Langerhans cells producing glucagon (Alpha cell) and insulin (beta cell)

Pancreatitis Acute- Inflammation of the pancreas resulting

from activated pancreatic enzymes autodigesting the pancreas

Mortality can be as high as 20%

Chronic – Progressive destruction of the pancreas with development of calcification and necrosis, possible resulting in hemorrahagic pancreatitis.

Mortality can be as high as 50%Block 7.0 Module 5.1


Acute Pancreatitis Life threatening inflammatory process

Patho: Premature activation of pancreatic enzymes that destroy ductal tissue and pancreatic cells

Etiology- Mostly unknown however most common causes are:

Excessive alcohol intakeBiliary tract disease with gallstonesTrauma-From surgical proceduresTrauma-From diagnostic procedure-ERCPFamilialDrug Use


Acute Pancreatitis

Clinical Manifestations

Jaundice Ascites Severe, usually sudden

onset abdominal/epigastric pain that radiates to back, left flank. Feels “boring” (a feeling like it is going thru the body)

Nausea, Vomiting, Wt. loss

Cullen and Turner signs

Diagnostics Serum Amylase (30-110u/L)

Rises within 12-24 hrs, last 4 days

Serum Lipase (3-73u/L)Rises slower but last up to 2 weeks

Lipase is usually more specific because the pancreas is the only organ that secretes lipase

Urine amylase Decrease in serum calcium

and magnesium Elevated WBCs Ultrasound and CT

Acute PancreatitisCullen’s Sign Turner’s Sign



Acute Pancreatitis-Complications Pancreatic infection (most common cause of death) Hypocalcemia Hypovolemia Type I diabetes-Total destruction of the pancreas Hemorrhage Septic Shock Paralytic ileus ARF Pneumonia, Atelectasis, Pleural Effusion, ARDS Coagulation defects- DIC


Nursing Care Priority is provide supportive care by

relieving symptoms and decreasing inflammation

Always ABCs Pain Management-Opioids, Dilaudid and MS IV Fluids, I & O Rest GI Tract- NPO Nutrition- TPN NG Tube No Smoking No Alcohol


Medication Management Spasmolytics- Pavabid, Cerespan Anticholinergics- Bentyl- Relieves spasms of

muscles in the stomach and intestines , reduces spasms of Sphincter of Oddi (contraindicated in paralytic ileus)

Histamine Receptor Antagonists (HCAs)-Suppress secretion of gastric acid by selectively blocking H2 receptors (Zantac)

Protein Pump Inhibitors (PPIs)- Prilosec Pancreatic Enzymes- Increases digestion of fats,

carbohydrates, and proteins in the GI tract Take immediately before meals with water Viokase, Donnazyme

Antibiotics


Chronic Pancreatitis Progressive disease with exacerbations

and remissions Usually develops after repeated episodes

of alcohol induced acute pancreatitis Also caused by chronic obstructive

disorders of the common bile duct Loss of exocrine function-Digestive

Enzymes Loss of endocrine function- Diabetes

Chronic PancreatitisClinical

Manifestations Intense abdominal

pain that is continuous, burning or gnawing

LUQ pain- ? Pseudocyst

Steatorrehea or Clay color stools

Weight loss Exacerbations

Iggy pg. 1378 chart 62-3

Nursing Care Prevent exacerbation Pain Management Pancreatic enzymes Monitor I&O, IV fluids Education: pancreatic

enzymes, diet, avoid smoking, caffeine, avoid alcohol, alcohol support groups

Comfort measures Insulin therapy Monitor calcium levels



Pancreatic Cancer Etiology-Unknown High incidence in age group 60-80 years High incidence in smokers 4th leading cause of cancer death in the U.S. Spreads rapidly through lymphatic and

venous systems to other organs Vague symptoms usually diagnosed after

there is already liver and gallbladder involvement

High mortality rate- Less than 20% live longer than 1 year after diagnosis

Clinical Manifestations Jaundice-May be first sign but signifies late

stage of disease Fatigue Clay colored stools Dark urine Abdominal pain-vague Weight loss, nausea, vomiting GI bleeding Anorexia Splenomegaly- if spleen involved Hepatomegaly-if liver is involved



Pancreatic Cancer-Diagnostics CT scan- visualization of the tumor Elevated serum amylase and lipase Elevated carcinoembryonic antigen (CEA) Elevated alkaline phosphatase and bilirubin ERCP- Most definitive- Allows for placement

of a drain or stent for biliary drainage Abdominal Paracentesis- Drains fluid and

tests for malignant cells


Endoscopic Retrograde Cholangiopancreatography (ERCP)


ERCP

Pancreatic Cancer- Treatments Management is geared toward preventing

tumor spread and decreasing pain. It is palliative not curative

Surgery- Whipple Procedure -Removal of the head of the pancreas, duodenum, parts of the jejunum and stomach, gallbladder, and possibly the spleen. The pancreatic duct is connected to the common bile duct. The stomach is connected to he jejunum

High Risk Follow with chemotherapy and radiation


Nursing CarePost op care- Usually ICU with Whipple

ProcedurePain management In addition to routine post op care:

Assess glucoseAssess bowel sounds and stoolsAssess for infectionsNPO- NG TubeTPN- Usually started pre-op*Assess for S+S of peritonitis- Board like

abdomen*Assess fluids and electrolytes and other labs????Block 7.0 Module 5.1


Liver Diseases Function of the Liver is to: Store Protect Metabolize

Cirrhosis Liver Cancer Liver Transplants Hepatitis


Liver (“Hepato-”) Disorders

Cirrhosis Extensive irreversible scarring of the

liver caused by a chronic reaction to hepatic inflammation and necrosis



Cirrhosis

Cirrhosis

Etiology

Alcohol (Laennec’s cirrhosis)

Hepatitis B,C, and D (Post necrotic cirrhosis)

Autoimmune hepatitis Steatohepatitis-(Fatty

Liver Disease) Drugs and toxins Biliary disease Cardiac cirrhosis-

(Caused by Heart Failure)

Clinical Manifestations

Fatigue Significant change in wt Confusion or difficult thinking GI symptoms and GI Bleeding ABD and liver pain Pruritus Ascites Jaundice and Icterus Petechiae Palmar Erythema Spider Angiomas Fector hepaticus Dependent edema of

extremities and sacrum Asterixis READ YOUR ATI BOOK



Ascites


DiagnosticsCheck Your ATI Book

Serum Liver Enzymes- ALT, AST,ALP- All Increase Serum Bilirubin- Direct, Indirect, and Total- All Increase Serum Protein and Serum Albumin- Decrease CBC- Values Decrease (anemia) PT/INR- Increase Serum Ammonia- Increase Abdominal X-Rays, Ultrasound, CT, MRI EGD- Detect bleeding or esophageal varices

Liver Biopsy- Most definitive-Measures progression and extent of cirrhosis

Cirrhosis Secondary to Hepatitis

Acute hepatitis A and acute hepatitis E do not lead to chronic hepatitis.

Acute hepatitis B leads to chronic hepatitis infection in approximately 5% of adult patients. In a few of these patients, the chronic hepatitis B progresses to cirrhosis.

Acute hepatitis D infects individuals already infected by hepatitis B.

Acute hepatitis C becomes chronic in approximately 80% of adults. A minority of these patients (20-30%) will progress to cirrhosis, typically over many years.



Nursing Care Comfort Measures Assess for Bleeding Complications- Blood

Transfusions as ordered: Usually RBCs and FFP Diet and Dietary Teaching

High Calorie, Moderate FatLow-SodiumLow-Protein if encephalopathy and ^

ammonia levelsSmall-frequent feedingsVitamin SupplementsTeach to Avoid Alcohol, May need Referrals

Non-Surgical Management Paracentesis- Remove and drain ascitic

fluid from the peritoneal cavity. Will relieve symptoms of fullness and respiratory distress



Nursing Implications for Paracentesis Explain procedure and answer questions Obtain consent Monitor vital signs Monitor color and amount of drainage Send fluid to lab for analysis Abdominal girth measurements before and

after Monitor puncture site for bleeding and

serous fluid oozing Monitor respiratory status before and after

Non-surgical Management TIPS- Transjugular Intrahepatic Portosystemic Shunt Used to control ascites and variceal bleeding Clients are discharged 2-4 days post procedure



Medications Careful!!!!- Many medications metabolized in the

liver. Caution with Opioids, Sedatives, Barbituates.

Diuretics- Monitor for hypokalemia and hypotension

H2 receptor Antagonists- For Stress Ulcers

Lactulose- Promotes excretion of ammonia via the stool

Neomycin and Flagyl- Removes intestinal bacteria which produces ammonia

Complications of Cirrhosis Portal Systemic Encephalopathy- Inability to remove ammonia

causes increased toxins to the brain. Clients develop neurological symptoms

Portal Hypertension

Splenomegaly

Esophageal Varices- Esophageal veins become distended due to increased pressure. Most often occur in the esophagus but can be present in stomach and rectum

Bleeding Esophageal Varices is a life-threatening medical emergency. Client may vomit large amounts of blood (hematemesis) or possess large amounts of black tarry stools (melena)


Esophageal VaricesTreatment is endoscopic scleral

therapyUse of a Blakemore Tube



Portal Hypertension Hepatic encephalopathy Esophageal varices Peritonitis Metabolic and respiratory acid-base

imbalance Systemic infections Malnutrition Death


Portal Hypertension


Hepatic Encephalopathy Clinical disorder seen in liver failure

patients Results from shunting of portal venous

blood and build up of toxic substances Ammonia crosses the blood brain barrier Stimulated by active GI bleeding Stages of Encephalopathy-Iggy- Pg.

1346 Table 61-2


Liver Cancer Most common Tumor is Hepatocellular

Carcinoma (HCC) Most tumors are unresectable 5-year survival rate is less than 90% Risk Factors- Cirrhosis, Alcohol, HBV and

HCV infections


Diagnostics Alpha-fetoprotein (AFT) is elevated Serum Liver Enzymes-Elevated Ultrasound CT Liver Biopsy-Most definitive, High risk

due to potential for bleeding


Liver Cancer-Clinical Manifestations Abdominal Discomfort Weight Loss, Anorexia Jaundice S+S of Cirrhosis Enlarged liver


Liver Transplant Most common reason for liver transplant is Hepatitis C Clients Not Considered Candidates: -Metastatic Tumors -Active alcohol/substance abuse -Severe cardiac & respiratory disease Can use a “lobe” of a liver for donation as the liver

will regenerate itself 12 hour surgery Goal: Prevent rejection Rejection occurs 4-10 days post-op (liver failure),

tachycardia, right upper flank pain, fever


Liver Transplant Nursing Care Post Transplant:

Monitor for S + S of rejectionCyclosporineVaccinations and AntibioticsPost-Op Care- Infection, Pain, Fluid Management, Monitor for bleeding problemsPsychosocial Support

Hepatitis Hepatitis is inflammation of the liver Types: HAV, HBV, HCV, HDV, HEV, HFV, HGV- Iggy

pgs 1356-1357 Viral Hepatitis can be acute or chronic

Clients can NEVER donate blood, body organs, or tissue

MUST report ALL cases of hepatitis to health department

All healthcare workers should have Hep B vaccination series



Risk Factors Ingestion of Contaminated Food or

Water- A,E Drug Abuse-B,C,D Sexual Contact-B,C Transmission by Infected Healthcare

Worker-B See ATI Chart- Pg 737


High Risk Behaviors Failure to Follow Universal Precautions Percutaneous Exposure- Sharps, Tattoos, Body-

Piercing, Contaminated needles Unprotected Sex Unscreened Blood Transfusions (prior to 1992) Travel in underdeveloped countries without

taking precautions (water) Crowded unsanitary environments TEACH!!!!!!!!!!!!!!!


DiagnosticsLab Tests

Serum liver enzymes-Elevated

Serum bilirubin-Elevated Serologic markers-

Presence of virus Hepatitis antibody

serum-Identifies exposure

Positive HBsAb indicates immunity to Hep B either following recovery or from successful vaccination

Diagnostics

Abdominal Films Liver biopsies-

Most definitive


Complications Chronic Hepatitis Fulminating hepatitis Cirrhosis of the liver Liver cancer Liver failure

HepatitisClinical Manifestations

Influenza symptoms

RUQ pain HBV:

hepatomegaly, light color stools, dark urine, jaundice

Nursing Interventions and Care Assessment-Skin, eyes, pain History-Contacts, Travel Contact isolation Limit Activity Diet-High calorie Education to prevent transmission Drug therapy:

Interferon( HBC,HCV)Monitor these clients for:

-flu like symptoms -alopecia -bone marrow suppression -N&V



End of Hepatobiliary

Adult Health Nursing II Block 7.0

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