Chapter 6 Care of the Patient with a Gallbladder, Liver, Biliary Tract,

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Chapter 6

Care of the Patient with a Gallbladder, Liver, Biliary Tract, or Exocrine Pancreatic Disorder

Chapter 6

Care of the Patient with a Gallbladder, Liver, Biliary Tract, or Exocrine Pancreatic Disorder

Liver, Biliary Tract, Pancreas, & Gallbladder Disorders

• Cirrhosis– Etiology/pathophysiology

• Chronic, degenerative disease of the liver

• Scar tissue restricts the flow of blood to the liver

• Types of cirrhosis– Laënnec’s cirrhosis

– Postnecrotic cirrhosis

– Primary biliary cirrhosis

– Secondary biliary cirrhosis


• Cirrhosis (continued)– Etiology/pathophysiology (continued)

• Alteration of liver function– Reduced ability to metabolize albumin

• Obstruction of portal vein– Increased pressure in veins that drain GI tract

• Complications– Portal hypertension

– Ascites

– Esophageal varices

– Hepatic encephalopathy

Liver, Biliary Tract, Gallbladder, & Pancreas Disorders

• Cirrhosis (continued)– Clinical manifestations/assessment

• Early stages– Abdominal pain

– Liver is firm and easy to palpate

• Late stages– Dyspepsia

– Changes in bowel habits

– Nausea and vomiting

– Gradual weight loss


• Cirrhosis (continued)– Clinical manifestations/assessment (continued)

• Late stages (continued)– Ascites

– Enlarged spleen

– Spider angiomas

– Anemia

– Bleeding tendencies

– Epistaxis


• Cirrhosis (continued)– Clinical manifestations/assessment

(continued)• Late stages (continued)

– Purpura

– Hematuria

– Bleeding gums

– Jaundice

– Disorientation

Figure 46-2

Systemic clinical manifestations of liver cirrhosis.

(From Lewis, S.M., Heitkemper, M.M., Dirksen, S.R. [2004]. Medical-surgical nursing: assessment and management of clinical problems. [6th ed.]. St. Louis: Mosby.)


• Cirrhosis (continued)– Medical management/nursing interventions

• Eliminate the cause– Alcohol

– Hepatotoxins

– Environmental exposure to harmful chemicals

• Antiemetics– Benadryl and Dramamine

– Contraindicated: Vistaril, compazine, and Atarax



(continued)• Diet

– Well-balanced

– High calorie

– Moderate protein

– Low fat

– Low sodium

– Supplemental vitamins and folic acid



(continued)• Treatment of complications

– Ascites

• Bedrest

• Strict I&O

• Restrict fluids and sodium

• Diuretics: aldactone, Lasix, HCTZ

• Vitamins K, C, and folic acid supplements

• LeVeen peritoneal-jugular shunt

• Paracentesis

Figure 46-3

LeVeen continuous peritoneal jugular shunt.

(From Beare, P.G., Myers, J.L. [1998]. Adult health nursing. [3rd ed.]. St. Louis: Mosby.)



(continued)• Treatment of complications (continued)

– Ruptured esophageal varices• Maintain airway; establish IV• Vasopressin drip to control bleeding• Sengstaken-Blakemore tube• Endoscopic sclerotherapy• Portacaval shunt• Blood transfusion



(continued)• Treatment of complications (continued)

– Hepatic encephalopathy• Decrease protein in diet• Avoid drugs which are detoxified by the liver• Lactulose• Neomycin


• Hepatitis– Etiology/pathophysiology

• Inflammation of the liver resulting from several types of viral agents or exposure to toxic substances

• Hepatitis A– Most common

– Oral-fecal transmission


• Hepatitis (continued)–Etiology/pathophysiology

• Hepatitis B– Transmission by contaminated serum; blood

transfusion, contaminated needles, dialysis, or direct contact with infected body fluids

• Hepatitis C– Transmitted through contaminated needles

and blood transfusions


• Hepatitis (continued)– Etiology/pathophysiology (continued)

• Hepatitis D– Co-infection with hepatitis B

• Hepatitis E– Fecal contamination of water– Rare in the U.S.; usually in developing

countries

HEPATITIS C


• Hepatitis (continued)– Clinical manifestations/assessment

• General malaise• Aching muscles• Photophobia• Headaches• Chills• Abdominal pain• Dyspepsia• Nausea


• Hepatitis (continued)– Clinical manifestations/assessment

• Diarrhea/constipation• Pruritus• Hepatomegaly• Enlarged lymph nodes• Weight loss• Jaundice• Dark amber urine• Clay-colored stools

Figure 46-5

Severe jaundice.

HEPATITIS


• Hepatitis (continued)– Medical management/nursing

interventions• Treat symptoms• Small, frequent meals

– Low fat, high carbohydrate

• IV fluids for dehydration• Vitamin C, vitamin B-complex, vitamin K• Avoid unnecessary medications, especially

sedatives


• Hepatitis (continued)– Medical management/nursing

interventions (continued)• Gamma globulin or immune serum globulin• Hepatitis B immune globulin (HBIG)

– Should be given to anyone exposed to hepatitis B

• Hepatitis B vaccine– Should be given to people identified as high risk

for developing hepatitis B


• Liver abscesses– Etiology/pathophysiology

• May be single or multiple

• Abscess forms in the liver due to an invading bacteria


• Liver abscesses (continued)– Clinical manifestations/assessment

• Fever• Chills• Abdominal pain and tenderness in the right upper

quadrant• Hepatomegaly• Jaundice• Anemia


• Liver abscesses (continued)– Medical management/nursing

interventions• IV antibiotics

• Percutaneous drainage of liver abscess

• Open surgical drainage


• Cholecystitis and cholelithiasis– Etiology/pathophysiology

• An obstruction, gallstone, or tumor prevents bile from leaving the gallbladder and the trapped bile acts as an irritant causing inflammation

• Risk factors– Female; American Indian or white; obesity;

pregnancy; diabetes; multiparous women; use of birth control

Figure 46-6

Common sites of gallstones.


• Cholecystitis and cholelithiasis Clinical manifestations/assessment

• Indigestion after eating foods high in fat• Severe, colicky pain in the right upper

quadrant• Anorexia• Nausea and vomiting• Flatulence • Increased heart and respiratory rates• Diaphoresis

GALLSTONES


• Cholecystitis and cholelithiasis (continued)– Clinical manifestations/assessment

(continued)• Low-grade fever

• Elevated WBC

• Mild jaundice

• Steatorrhea (fatty stool)

• Dark amber urine


• Cholecystitis and cholelithiasis – Medical management/nursing

interventions• Mild attacks

– Bedrest

– NG tube to suction

– NPO

– IV fluids

– Antispasmodic/analgesic

– Antibiotics

– Avoid spicy foods when allowed PO intake


• Cholecystitis and cholelithiasis– Medical management/nursing

interventions (continued)• Lithotripsy

• Cholecystectomy– Laparoscopic– Open


PancreatitisEtiology/pathophysiology

Inflammation of the pancreasAcute or chronic

Predisposing factorsAlcohol

Trauma

Infectious disease

Certain drugs


• Pancreatitis (continued)– Clinical manifestations/assessment

• Abdominal pain• Anorexia; nausea and vomiting• Malaise• Low-grade fever• Jaundice• Weight loss• Steatorrhea• Tachycardia


• Pancreatitis (continued)– Medical management/nursing

interventions• NPO• IV fluids• NG tube• Antiemetics• Demerol 75-100 mg every 3-4 hours• Anticholinergics• Antacids or Tagamet (prevent ulcers)• Hyperalimentation

Figure 46-9

Whipple’s procedure, or radical pancreaticoduodenectomy.

(From Lewis, S.M., Heitkemper, M.M., Dirksen, S.R. [2004]. Medical-surgical nursing: assessment and management of clinical problems. [6th ed.]. St. Louis: Mosby.)

NURSING PROCESS

• NURSING DIAGNOSIS– Activity intolerance– Breathing pattern, ineffective– Fluid volume, deficient– Home maintenance, impaired– Injury, risk for– Knowledge, deficient

NURSING PROCESS

– Noncompliance– Nutrition, imbalanced, less than body

requirements– Pain, acute/chronic– Powerlessness– Skin integrity, impaired– Thought processes, disturbed

QUOTE

• "Don't procrastinate. Putting off an unpleasant task until tomorrow simply gives you more time for your imagination to make a mountain out a possible molehill. More time for anxiety to sap your self-confidence. Do it now, brother, do it now. " Author Unknown, from Ten Ways to Worry Less and Accomplish More

http://www.wow4u.com/tenways/index.html



Chapter 24Agents Used to Treat Hyperacidity and

Gastroesophageal Reflux Disease

Secretory Functions of the Stomach Lining

• Parietal cells secrete hydrochloric (HCl) acid

• Chief cells secrete pepsinogen

• Mucoid cells secrete mucus

Stomach Hyperchlorhydria• Produced from:

– Eating high-fat meals– Increased alcohol intake– Emotional turmoil

Goal of Antacid Therapy

• Neutralize the acid

• Inhibit pepsin activity

• Increase resistance of the stomach lining

• Increase tone of the lower esophageal sphincter

AntacidsThree Forms

1. Aluminum

2. Magnesium

3. Calcium

• Mechanism of action– Neutralization of gastric acidity– Low doses promote gastric mucosal

defensive mechanisms

Systemic Antacids• Useful in short-term therapy

• Rapid onset

• Prolonged use causes an overload on the kidneys– Example: sodium bicarbonate

Nonsystemic Antacids

• Remain in gastrointestinal tract; useful in long-term therapy

• Most of the dose remains in the gastrointestinal tract

• Will not alter acid-base system– Examples: calcium carbohydrate (Tums,

Rolaids), aluminum carbonate (Basaljel), magaldrate (Riopan), etc.

Side Effects and Adverse Effects

• Magnesium: diarrhea

• Aluminum: constipation

• Calcium: constipation

Antacid Interactions• Binding of other drugs to the antacid

causes reduced availability of the other drugs to the client.

• Chemical inactivation

• Increases stomach and urine pH (alkaline), which decreases the absorption and excretion of certain drugs

Nursing Interventions

• Monitor for side effects– Nausea, vomiting, abdominal pain,

diarrhea– With calcium-containing products:

constipation, acid rebound

• Monitor for therapeutic response– Notify heath care provider if symptoms

are not relieved.

Histamine (H2) Receptor Antagonists

• Examples– Cimetadine (Tagamet)– Famotidine (Pepcid)– Nizatidine (Axid)– Ranitidine (Zantac)

Proton Pump Inhibitors• Omeprazole (Prilosec)

– Blocks the final step of acid production in the stomach

• Indicated for clients with:– Gastroesophageal reflux disease (GERD)– Gastric hypersecretory condition

• Interactions– Causes warfarin (an anticoagulant) action

to be increased

Helicobacter Pylori

• An organism associated with the development of peptic ulcer disease

• Treatment– Metronidazole (Flagyl), an antimicrobial

agent, along with bismuth subsalicylate (Pepto-Bismol) and tetracycline (antimicrobial) for 4 weeks to eradicate Helicobacter pylori

Metoclopramide (Reglan) • A drug that stimulates the motility of the

upper GI tract without stimulating the production of gastric, biliary, or pancreatic solutions

• Action– Increases peristalsis in the duodenum and

jejunum– Decreases gastroesophageal reflux

(continues)

Metoclopramide (Reglan)

• Adverse effects– Produces extrapyramidal (Parkinson-like

symptoms) effects– Central nervous system depression– Gastrointestinal upset

(continued)

Chapter 25

Emetics and Antiemetics

Emetics • Agents that induce vomiting

– Used in overdoses

• Example– Ipecac syrup

• Inappropriate use– Clients with bulimia

Antiemetics

Five categories of antiemetics

1. Anticholinergics

2. Antihistamines

3. Neuroleptic agents

4. Prokinetic agents

5. Serotonin blockers

Anticholinergics and Antihistamines

• Anticholinergics– Bind to and block acetylcholine

receptors• Prevent nausea stimuli from being

transmitted

• Antihistamines– Block H2 receptors

• Prevent cholinergic stimulation

Neuroleptic and Prokinetic Agents

• Neuroleptic agents– Bind to the dopamine receptors and

block action• Limit dopamine activity

• Prokinetic agents– Block dopamine– Stimulate acetylcholine to increase

gastric emptying

Serotonin Blockers• Block serotonin receptors in the

gastrointestinal tract

• Block serotonin receptors in the central nervous system (emetic center)– Used often when antineoplastic

agents are being given

Anticholinergics and Antihistamines

• Anticholinergics– Scopolamine (Trans Scop)

• Antihistamines– Promethazine (Phenergan)– Meclizine (Antivert)

Emetics and Antiemetics

• Neuroleptic agents– Chlorpromazine (Thorazine)

• Prokinetic agents– Metoclopramide (Reglan)

• Serotonin blockers– Ondansetron (Zofran)

Side Effects and Adverse Effects• General

– Dizziness– Drowsiness– Dry mouth– Headache

Nursing Process• Assessment

– Thorough history and physical

• Plan– Use proper route

• Implementation– Safely administer medication

• Evaluation– Are the nausea and vomiting gone?

Chapter 26

Laxatives and Antidiarrheals

Laxative Classifications• Stimulant

• Saline

• Bulk-forming

• Lubricant– Stool softeners– Suppositories

• Lactulose

• Enemas

Stimulant Laxatives• Action

– Chemical irritation• Increase motility of the GI tract

– Increase secretion of water into large and small intestine• Example: bisacodyl

Saline Laxatives• Increase osmotic pressure within

the intestinal tract– Cause more water to enter the

intestines

– Result in: • Bowel distention, increased

peristalsis, and evacuation

(continues)

Saline Laxatives• Contain salt

• Unpleasant taste

• Systemically absorbed

• Result in:– Poor client compliance– Risk for dehydration – Risk for congestive heart failure

(continued)

Bulk-Forming Laxatives• Safest form

– Absorbs water to increase bulk – Distends bowel to initiate reflex bowel

activity• Not systemically absorbed

– High fiber – Natural or semisynthetic

• Examples: psyllium hydrophilic muciloid (Metamucil), methylcellulose (Citrucel), and polycarbophil (Fibercon)

(continues)

Bulk-Forming Laxatives• Must be followed with a large amount

of fluid– If chewed or taken in dry powder form,

these agents can cause esophageal obstruction and/or fecal impaction.

(continued)

Lubricant Laxatives• Oils lubricate the fecal material

and intestinal walls, thereby promoting fecal passage:

– Prevent fat-soluble vitamins from being absorbed

• Popular lubricant– Mineral oil (liquid petroleum)

• Not digested or absorbed

Stool Softeners • Detergent-like drugs:

– Permit mixing of fats and fluids with the fecal mass

– Stool becomes softer and is passed much easier

– Takes several days to work

• Example: docusate salts (Colace and Surfak)

Suppositories • Usually in a wax base

• Administered rectally

• Absorbed systemically

• Available containing stimulant drugs– Glycerin

• Absorbs water from tissues, creating more mass

– Bisacodyl • Induces peristaltic contraction by direct

stimulation of sensory nerves

Lactulose Laxatives• Two monosaccharides that are not

digested or absorbed

• Digested in the colon by bacteria to form acids substances

– Acid substances cause water to be drawn into the colon

GoLYTELY • Polyethylene glycol (electrolyte

solution and salt)– Must consume 4 liters within 3

hours

– Causes a large volume of water to be retained in the colon

– Acts within one hour• Produces a diarrheal state

Enemas• Hyperosmotics

– Solution contain salts (e.g., Fleet enema) • Administered rectally and cause a

laxative effect by osmotically drawing fluid into the colon to initiate defecation

Long-Term Use• Long-term use of laxatives often

results in decreased bowel tone and may lead to dependency.

• Encourage– A healthy, high-fiber diet– Increased fluid intake

Adsorbents• Most commonly used

• Claylike materials administered in a tablet or liquid suspension form after each loose bowel movement

• Bind to the causative bacteria or toxin, and are eliminated through the stool

• Little scientific proof that they work– Examples: kaolin-pectin, attapulgite

(Kaopectate)

Antidiarrheals• Reduce GI motility• Opium is a narcotic.

– Decreases bowel motility and rectal spasms

– Depresses the CNS; monitor closely– Decreases transit time through the

bowel; more time for water and electrolytes to be absorbed

• Paregoric is an opium tincture.– May cause physical dependence (continues)

Antidiarrheals• Loperarmide HCl (Imodium)

– Made from chemicals related to meperidine, a narcotic

• Diphenoxylate HCl and atropine sulfate (Lomotil)– Narcotic and anticholinergic drug

• Reduces GI motility

(continued)

Anticholinergics• Decrease intestinal muscle tone

and peristalsis of GI tract

• Result: slows the movement of fecal matter through the GI tract

– Example: belladonna alkaloids (Donnatal)

Nursing Implications• Monitor for therapeutic effect

Chapter 6 Care of the Patient with a Gallbladder, Liver, Biliary Tract,

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Transcript of Chapter 6 Care of the Patient with a Gallbladder, Liver, Biliary Tract,