Chapter 62 - PowerPoint Presentation

Slide1

Chapter 62

Care of Patients with Problems of the Biliary System and Pancreas

Mrs. Kreisel MSN, RN

NU130 Adult Health

Summer 2011Slide2

Hepatobiliary AnatomySlide3

Acute Cholecystitis

Acute cholecystitis is the inflammation of the gallbladder.Calculous cholecystitis.

Cholelithiasis (gallstones) usually accompanies cholecystitis.

Acalculous cholecystitis inflammation can occur in the absence of gallstones.Slide4

GallstonesSlide5

Chronic Cholecystitis

Repeated episodes of cystic duct obstruction result in chronic inflammationPancreatitis, cholangitis

Jaundice

Icterus

Obstructive jaundice

Pruritus Slide6

Clinical Manifestations

Flatulence, dyspepsia, eructation, anorexia, nausea and vomiting, abdominal pain Biliary colic

Murphy’s sign

Blumberg’s sign

Rebound tenderness

Steatorrhea Slide7

Nonsurgical Management

Nutrition therapy—low-fat diet, fat-soluble vitamins, bile salts

Drug therapy

—o

pioid analgesic such as morphine or hydromorphone, anticholinergic drugs, antiemetic

Extracorporeal shock wave lithotripsy

Percutaneous transhepatic biliary catheter insertionSlide8

Surgical Management

Laparoscopic cholecystectomyStandard preoperative care

Operative procedure

Postoperative care:

Free air pain result of carbon dioxide retention in the abdomen

Ambulation

Return to activities in 1 to 3 weeksSlide9

Traditional Cholecystectomy

Standard preoperative careOperative procedure

Postoperative care:

Opioids via patient-controlled analgesia pump

T-tube

Antiemetics

Wound careSlide10

Traditional Cholecystectomy (Cont’d)

Care of the T-tubeNPO

Nutrition therapySlide11

Cancer of the Gallbladder

Anorexia, weight loss, nausea, vomiting, general malaise, jaundice, hepatosplenomegaly; chronic, progressively severe epigastric or right upper quadrant pain

Poor prognosis

Surgery, radiation, chemotherapySlide12

Acute Pancreatitis

Serious and possibly life-threatening inflammatory process of the pancreasNecrotizing hemorrhagic pancreatitis

Lipolysis

Proteolysis

Necrosis of blood vessels

Inflammation

Theories of enzyme activationSlide13

Autodigestion Slide14

Complications of Acute Pancreatitis

HypovolemiaHemorrhage

Acute renal failure

Paralytic

ileus

Hypovolemic

or septic

shock

Pleural effusion, respiratory distress syndrome, pneumonia

Multisystem organ failure

Disseminated intravascular coagulation

Diabetes mellitusSlide15

Clinical Manifestations

Generalized jaundiceCullen’s sign

Turner’s sign

Bowel sounds

Abdominal tenderness, rigidity, guarding

Pancreatic ascites

Significant changes in vital signsSlide16

Laboratory Assessment

LipaseTrypsinAlkaline phosphatase

Alanine aminotransferase

WBC

Glucose

CalciumSlide17

Acute Pain

Interventions include:The priority for patient care to provide supportive care by relieving symptoms, decrease inflammation, and anticipate and treat complications

Comfort measures to reduce pain including fasting and drug therapy

Endoscopic retrograde cholangiopancreatography Slide18

Nonsurgical Management

Fasting and restDrug therapy

Comfort measures

Endoscopic retrograde cholangiopancreatography (ERCP)Slide19

Surgical Management

Preoperative care—NG tube may be inserted

Operative procedures

Postoperative care:

Monitor drainage tubes and record output from drain.

Provide meticulous skin care and dressing changes.

Maintain skin integrity.Slide20

Imbalanced Nutrition: Less Than Body Requirements

Interventions include:NPO in early stages

Antiemetics for nausea and vomiting

Total parenteral nutrition

Small, frequent, moderate- to high-carbohydrate, high-protein, low-fat meals

Avoidance of foods that cause GI stimulationSlide21

Chronic Pancreatitis

Progressive destructive disease of the pancreas, characterized by remissions and exacerbationsNonsurgical management includes:

Drug therapy

Analgesic administration

Enzyme replacement

Insulin therapy

Nutrition therapySlide22

Pancreatic Abscess

Most serious complication of pancreatitis; always fatal if untreatedHigh fever

Blood cultures

Drainage via the percutaneous method or laparoscopy

Antibiotic treatment

alone does not resolve abscessSlide23

Pancreatic Pseudocyst

Complications: hemorrhage, infection, bowel obstruction, abscess, fistula formation, pancreatic ascitesMay spontaneously resolve

Surgical intervention after 6 weeksSlide24

Insulinoma

Most common type of neuroendocrine pancreatic tumorBenign tumors of the islets of Langerhans that cause excessive insulin secretion and subsequent hypoglycemia

Management

—

removal of tumorSlide25

Pancreatic Carcinoma

Nonsurgical management:Drug therapy

Radiation therapy

Biliary stent insertionSlide26

Surgical Management

Preoperative care:NG tube may be inserted

TPN typically begun

Operative procedure may include Whipple procedureSlide27

Surgical Management (Cont’d)

Postoperative care:Observe for complicationsGI drainage monitoring

Positioning

Fluid and electrolyte assessment

Glucose monitoringSlide28

Whipple Procedure

Three anastomoses that constitute the Whipple procedure: Choledochojejunostomy

,

pancreaticojejunostomy

,

&

gastrojejunostomy

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NCLEX TIMESlide30

Question 1

A patient with chronic cholecystitis is complaining of pruritus, clay-colored stools, and voiding dark, frothy

urine. Which laboratory analysis is a priority in the

nurse’s assessment of this patient?

Liver function tests

Total bilirubin

Lipase level

White blood cell countSlide31

Question 2

Which patient is more likely to develop gallstones?

55-year-old African-American male with a history of diabetes mellitus

62-year-old American-Indian female

45-year-old Caucasian female with a family history of gallstones

60-year-old obese, Mexican-American female with a history of diabetes mellitusSlide32

Question 3

The nurse notes jaundice and bluish discoloration of the

abdomen and flank in the patient complaining of

abdominal pain of sudden onset that radiates to the left

shoulder. Based on these symptoms, what intervention

should be the priority for this patient?

Passage of a nasogastric tube

Observation for delirium tremens

Pain relief

Relief from vomitingSlide33

Question 4

About how any Americans are affected by acute

pancreatitis?

10,000

30,000

50,000

80,000

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Question 5

In the care of a patient with acute pancreatitis, which

assessment parameter requires immediate nursing

intervention?

Heart rate 105 beats/min

Blood pressure 110/82 mm Hg

Respiratory rate 28 breaths/min

Serum glucose 136 mg/dL