logging in or signing up Nursing Care of the Liver, Gallbladder, jbarnes4 Download Post to : URL : Related Presentations : Share Add to Flag Embed Email Send to Blogs and Networks Add to Channel Uploaded from authorPOINT lite Insert YouTube videos in PowerPont slides with aS Desktop Copy embed code: (To copy code, click on the text box) Embed: URL: Thumbnail: WordPress Embed Customize Embed The presentation is successfully added In Your Favorites. Views: 2397 Category: Education License: All Rights Reserved Like it (2) Dislike it (0) Added: February 08, 2010 This Presentation is Public Favorites: 7 Presentation Description Nursing Care of the Liver, Gallbladder, and Pancreatic disorders, Level 1 Comments Posting comment... By: reynel89 (15 month(s) ago) Good day! I would like to ask your kind permission to allow me to add your wonderful presentation to this channel http://www.authorstream.com/channels/reynel89/Nursing/ Thank you very much. Saving..... 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Edit Comment Close Premium member Presentation Transcript NUR 173 : NUR 173 Nursing Care of Clients with Gallbladder, Liver, & Pancreatic Disorders Chapter 24 1 Gallbladder disorders : Gallbladder disorders Alteration in flow of bile via the hepatic, cystic or common bile duct Cholelithiasis - formation of gallstones leads to: Cholecysitis - inflammation Cholangitis - duct inflammation choledocolithiasis - stone in the common bile duct 2 Cholelithiasis : Cholelithiasis Formation of stones within the gallbladder or biliary duct system made up of bile pigments or hardened cholesterol cholesterol stones are more common stone formation occurs when the bile crystallizes contributing factors include stasis of bile in the gallbladder and bile concentration 3 Cholelithiasis : Cholelithiasis 4 Risk factors for cholelithiasis : Risk factors for cholelithiasis Age Family history of gallstones Race or ethnicity; Gender Diseases or conditions cirrhosis, ileal disease, sickle-cell anemia, hyperlipidemia, obesity and rapid weight loss, DM Biliary stasis Oral contraceptives with high estrogen content 5 Manifestations of Cholelithiasis : Manifestations of Cholelithiasis Stones in cystic duct severe, cramplike, colicky pain right upper abd pain nausea vomiting Obstruction of CBD jaundice pain hepatic damage pancreatitis sepsis clay colored stools 6 Manifestations of Cholelithiasis continued : Manifestations of Cholelithiasis continued Epigastric pain Heartburn Right upper abdominal pain (may radiate to subscapular area) Intolerance to fat-containing foods Jaundice 7 Cholecystitis : Cholecystitis Inflammation of the gallbladder Most commonly associated with stones in the cystic or CBD 5% of cases are acalculous may be related to trauma, hyperalimentation, extended fasting, surgery 8 Manifestations of Cholecystitis : Manifestations of Cholecystitis Acute severe spasmodic pain (usually initiated by high-fat meal) N&V low-grade fever jaundice Chronic long-term intolerance to fatty foods vague gastric symptoms flatulence 9 Additional manifestations of Cholecystitis : Additional manifestations of Cholecystitis High WBC count Abd muscle guarding with rebound tenderness and rigidity (may indicate peritoneal involvement) Elevated serum bilirubin Elevated alkaline phosphatase Elevated serum amylase if pancreatic ducts are involved 10 Complications of chronic cholecystitis : Complications of chronic cholecystitis Gangrene and perforation with peritonitis Empyema Fistula formation Gallstone ilius causing SBO 11 Gangrenous gallbladder with stones : Gangrenous gallbladder with stones 12 Laboratory and Diagnostic Tests : Laboratory and Diagnostic Tests CBC Serum amylase and lipase Serum bilirubin levels Flat plate of abd Oral cholecystogram Ultrasound Gallbladder scans 13 Collaborative CarePharmacology : Collaborative CarePharmacology Dissolvers Agents used for palliative relief of symptoms antibiotics Questran narcotics 14 Collaborative CareDiet Therapy : Collaborative CareDiet Therapy Low-fat diet May need fat soluble vitamins Obese clients are encouraged to lose weight NPO if client has severe N&V &/or NGT 15 Collaborative CareSurgery : Collaborative CareSurgery Cholecystectomy open or laparascopic Chole with CBD exploration and T-tube insertion T-tube maintains patency of the duct and promotes bile passage while the edema decreases 16 T-tube : T-tube 17 Nursing Diagnoses : Nursing Diagnoses Pain Imbalanced Nutrition: Less Risk for Infection Others? 18 Cancer of the Gallbladder : Cancer of the Gallbladder Rare Primarily affects people over age 65 More women than men 95% of clients with primary CA of gallbladder die within one year despite radical and extensive surgical interventions 19 Cancer of the Gallbladder : Cancer of the Gallbladder Manifestations intense pain in RUQ (may be able to palpate mass) jaundice/ green color pruritis weight loss Metastasis via the blood, lymph system, or through direct extension; liver is most commonly affected 20 Hepatitis : Hepatitis Inflammation of the liver, usually caused by a virus Other causes include ETOH, toxins (drugs), cholestasis due to hepatobiliary disease. May be secondary to other systemic vial infections Underlying pathophysiology varies with different types of hepatitis 21 Slide 22: 22 Viral Hepatitis : Viral Hepatitis Hepatitis A transmitted by oral-fecal route contaminated food, water, shellfish, intimate contact with carriers of the virus Hepatitis B transmitted to parenteral innoculation with contaminated blood or blood products, sexually transmitted disease 23 Manifestations of Hepatitis : Manifestations of Hepatitis Preicteric phase mimics influenza malaise, GI complaints including N&V, diarrhea, anorexia headache, fatigue, fever myalgia, polyarthritis sore throat, elevated LFTs right upper abd pain upon palpation 24 Manifestations of Hepatitis : Manifestations of Hepatitis Icteric phase jaundice of skin, sclera, and mucous membranes pruritus light brown or clay colored stools tea-colored urine appetite increases, temperature returns to normal 25 Manifestations of Hepatitis : Manifestations of Hepatitis Posticteric phase lasts several weeks manifestations gradually improve serum bilirubin & enzymes decrease to normal hepatic pain decreases GI symptoms and weakness subside Energy levels increase 26 Laboratory and Diagnostic Tests : Laboratory and Diagnostic Tests Multiple antigen, antibody tests Liver enzymes Conjugated and unconjugated bilirubin Prothrombin time Liver biopsy Liver scan 27 PharmacologyPrevention - Vaccination : PharmacologyPrevention - Vaccination Hepatitis A vaccine – One dose usually gives immunity but two are recommended. Hepatitis B vaccination—Three doses recommended for nurses and at risk health care workers and infants 28 PharmacologyPostexposure Prophylaxis : PharmacologyPostexposure Prophylaxis Hepatitis A--single dose of IG given within 2 weeks after exposure Recommended for all persons with household or sexual contact with a person known to be infected with Hepatitis A 29 PharmacologyPostexposure Prophylaxis : PharmacologyPostexposure Prophylaxis Hepatitis B--HBIG for short term; HBV vaccine given concurrently for long-term immunity 30 Collaborative Care : Collaborative Care Bed rest as needed Standard precautions & meticulous hand-washing Contact isolation if incontinent of feces Adequate nutrition as tolerated - high calorie Avoidance of strenuous activity, ETOH, and agents that are toxic to the liver 31 Nursing Diagnoses : Nursing Diagnoses Risk for Infection (Transmission) Fatigue Imbalanced Nutrition: Less Disturbed Body Image Others Knowledge Deficit Pain Risk for FVD 32 Cirrhosis of the Liver : Cirrhosis of the Liver Chronic disease that results in extensive hepatocellular damage Liver parenchyma is destroyed, regenerates, and eventually becomes scarred and fibrotic Loss of liver function occurs Systemic effects on the body Manifestations are r/t extent of liver damage 33 Manifestations of CirrhosisPortal hypertension : Manifestations of CirrhosisPortal hypertension Blood is rerouted to adjoining vessels that normally have lower BP than the portal vein Affected veins in the esophagus, rectum, and abdomen become engorged and congested Contributes to hydrostatic pressure ascites 34 Portal Venous System : Portal Venous System 35 Slide 36: 36 Manifestations of CirrhosisSplenomegly : Manifestations of CirrhosisSplenomegly Occurs in client with portal HTN as a result of the shunting of blood into the splenic vein Can result in hematological disorders such as anemia, thrombocytopenia, and leukopenia 37 Manifestations of CirrhosisAscites : Manifestations of CirrhosisAscites Accumulation of plasma-rich fluid in the peritoneal cavity serum proteins and aldosterone contribute to fluid accumulation Anasarca - generalized edema 38 Ascites : Ascites 39 Manifestations of CirrhosisEsophageal Varices : Manifestations of CirrhosisEsophageal Varices Enlarged, overdistended veins formed when portal venous system is congested and collateral veins become engorged with venous blood Clients are at risk for bleeding even high-roughage foods can precipitate bleeding thrombocytopenia contributes to increased risk of bleeding 40 Manifestations of CirrhosisHepatic Encephalopathy : Manifestations of CirrhosisHepatic Encephalopathy Accumulation of toxic substances (ammonia and others) in the circulation causes cognitive and motor changes Asterixis (early sign), then changes in personality and mentation occur Coma is final stage Process can be reversed or improved by body’s nitrogenous waste load 41 Laboratory and Diagnostic Tests : Laboratory and Diagnostic Tests Serum electrolytes & glucose, CBC Bilirubin levels, LFTs Total protein, serum albumin Ammonia levels, Coagulation studies Ultrasound Esophagoscopy Liver biopsy 42 Collaborative CarePharmacology : Collaborative CarePharmacology Diuretics Aldactone, Lasix Lactulose and Neomycin Vitamin K Antacids Avoid medications metabolized by the liver--barbituates, sedatives, hypnotics, Acetaminophen 43 Collaborative CareTreatments : Collaborative CareTreatments Sclerotherapy for esophageal varices Paracentesis Gastric lavage Balloon Tamponade Peritoneovenous shunt LeVeen shunt TIPS shunt (pg 593) Liver transplantation 44 Collaborative CareNutritional Considerations : Collaborative CareNutritional Considerations Restrict sodium intake Fluid restriction Dietary protein adjusted to client’s ability to handle the nitrogenous load High calorie, moderate fat intake during healing process Vitamin and mineral supplements 45 Nursing Diagnoses : Nursing Diagnoses Excess Fluid Volume Disturbed Thought Processes Ineffective Protection (bleeding) Impaired Skin Integrity Imbalanced Nutrition: Less Others- Risk for Infection Knowledge Deficit 46 Cancer of the Liver : Cancer of the Liver Primary hepatic CA uncommon in US Metastasizes to the liver from pulmonary, breast, and GI tract Poor prognosis 47 Causes of Primary Hepatic CA : Causes of Primary Hepatic CA Chronic Hepatitis B or C infection Chronic cirrhosis, regardless of type Chronic aflatoxin Arsenic contaminated water Hepatocarcinogenic pesticides in foods Hormonal factors Prolonged androgen therapy Contraceptive steroids 48 Manifestations of primary hepatic CA : Manifestations of primary hepatic CA Malaise, Lethargy Painful mass in RUQ Fullness in epigastric region Weight loss Anorexia FUO Signs of hepatic failure 49 Collaborative Care : Collaborative Care Partial hepatectomy single lesions without extrahepatic manifestations Liver transplantation RT Chemotherapy Chemoembolization 50 Nursing care : Nursing care Similar to care for patients with cirrhosis Avoid alcohol Pain control 51 Acute Pancreatitis : Acute Pancreatitis Inflammatory disorder that results in self-destruction of the pancreas by its own enzymes through autodigestion More common in middle adults Higher incidence in men than women Most often associated with gallstones in women and alcoholism in men 52 Factors that activate pancreatic enzymes : Factors that activate pancreatic enzymes Obstruction by a gallstone Obstruction of bile ducts Contents of duodenum (with activated pancreatic enzymes) back up into pancreas Excess HCl causes spasms of sphincter of Oddi and ampulla of Vater, obstructing pancreatic fluid flow 53 Pancreatitis secondary to choleliathesis : Pancreatitis secondary to choleliathesis 54 Pancreatitis secondary to choleliathesis : Pancreatitis secondary to choleliathesis 55 Factors associated with acute pancreatitis : Factors associated with acute pancreatitis Trauma or surgery Pancreatic tumors Third-trimester pregnancy Infectious agents Elevated calcium levels Hyperlipidemia Certain medications 56 Pathophysiology of acute pancreatitis : Pathophysiology of acute pancreatitis Release of pancreatic enzymes into the pancreatic tissue In hemorrhagic pancreatitis, enzymes cause fat necrosis of acinar cells and blood vessels large volume of fluid may shift from the circulating blood volume 57 Manifestations of acute pancreatitis : Manifestations of acute pancreatitis Continuous severe epigastric and abdominal pain N&V Abd distention and rigidity Decreased bowel sounds Signs of hypovolemic shock Mild jaundice may appear within 24 hr 58 Complications of acute pancreatitis : Complications of acute pancreatitis Development of DM Tetany Hypovolemic shock Pancreatic pseudocyst Abscess formation Peritonitis 59 Complications of acute pancreatitis : Complications of acute pancreatitis pleural effusion ARDS MODS renal failure ascites cardiac failure death 60 Chronic Pancreatitis : Chronic Pancreatitis Progressive disease that causes normal pancreatic tissue to be replaced by connective tissue Irreversible process that leads to pancreatic insufficiency Higher incidence in people aged 40-60 May follow acute pancreatitis or have no identifiable cause 61 Chronic Pancreatitis : Chronic Pancreatitis Recurrent episodes of inflammation eventually lead to changes in parenchyma loss of exocrine and endocrine functions malabsorption from pancreatic insufficiency DM from inability to produce insulin 62 Manifestations of chronic pancreatitis : Manifestations of chronic pancreatitis Upper abd pain radiating to the back N&V with weight loss Flatulence and constipation Steatorrhea Manifestations of malabsorption, DM Elevated serum and urinary amylase Elevated serum bilirubin 63 Laboratory and Diagnostic Tests : Laboratory and Diagnostic Tests Ultrasound CT scan ERCP Endoscopic ultrasonography Percutaneous fine-needle aspiration biopsy 64 Collaborative CarePharmacology : Collaborative CarePharmacology Demerol Antacids H2 blockers Proton pump inhibitors Antispasmodics Pancreatic enzyme supplements, insulin (chronic pancreatitis) 65 Collaborative CareDietary management : Collaborative CareDietary management NPO (insertion of NGT) TPN or IV fluids Oral food and fluids are begun once the serum amylase levels have returned to normal, bowel sounds are present, and pain disappears begins clear liquids and progresses to a low-fat diet as tolerated 66 Collaborative CareSurgery : Collaborative CareSurgery Endoscopic transduodenal sphincterotomy Cholecystectomy Surgical resection of pancreas to remove necrotic tissue Percutaneously inserted tubes to drain pseudocyst or abscess 67 Nursing Diagnoses : Nursing Diagnoses Pain Risk for Altered Nutrition: Less Risk for FVD Ineffective Breathing Pattern Risk for Infection Impaired Gas Exchange Altered Health Management Knowledge Deficit 68 Pancreatic Cancer : Pancreatic Cancer More common in adults over 50 Lethal- 98% with pancreatic CA die Incidence is higher in women than men and higher in African Americans than Caucasians Most occur in exocrine pancreas, are adenocarcinomas, and cause death in 1-3 years after diagnosis 69 Risk factors for Pancreatic CA : Risk factors for Pancreatic CA MAJOR RISK FACTOR IS SMOKING incidence is twice as high in smokers than nonsmokers Exposure to industrial chemicals or environmental toxins High-fat diet Pancreatitis DM 70 Manifestations of Pancreatic CA : Manifestations of Pancreatic CA Anorexia, nausea, weight loss, flatulence Dull epigastric pain that increases in severity as the tumor grows Late manifestations include palpable abdominal mass and ascites 71 Anatomy : Anatomy 72 Manifestations of Pancreatic CA : Manifestations of Pancreatic CA Head--jaundice, clay-colored stools, dark urine, pruritis Body--pain that increases when the person eats or lies supine Tail--no symptoms until it has metastasized 73 Collaborative Care : Collaborative Care Whipple’s procedure RT Chemotherapy Nursing Diagnoses?? 74 Slide 75: 75 You 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Nursing Care of the Liver, Gallbladder, jbarnes4 Download Post to : URL : Related Presentations : Share Add to Flag Embed Email Send to Blogs and Networks Add to Channel Uploaded from authorPOINT lite Insert YouTube videos in PowerPont slides with aS Desktop Copy embed code: (To copy code, click on the text box) Embed: URL: Thumbnail: WordPress Embed Customize Embed The presentation is successfully added In Your Favorites. Views: 2397 Category: Education License: All Rights Reserved Like it (2) Dislike it (0) Added: February 08, 2010 This Presentation is Public Favorites: 7 Presentation Description Nursing Care of the Liver, Gallbladder, and Pancreatic disorders, Level 1 Comments Posting comment... By: reynel89 (15 month(s) ago) Good day! I would like to ask your kind permission to allow me to add your wonderful presentation to this channel http://www.authorstream.com/channels/reynel89/Nursing/ Thank you very much. Saving..... Post Reply Close By: jbarnes4 (5 month(s) ago) Feel Free to do so. Saving..... Edit Comment Close Premium member Presentation Transcript NUR 173 : NUR 173 Nursing Care of Clients with Gallbladder, Liver, & Pancreatic Disorders Chapter 24 1 Gallbladder disorders : Gallbladder disorders Alteration in flow of bile via the hepatic, cystic or common bile duct Cholelithiasis - formation of gallstones leads to: Cholecysitis - inflammation Cholangitis - duct inflammation choledocolithiasis - stone in the common bile duct 2 Cholelithiasis : Cholelithiasis Formation of stones within the gallbladder or biliary duct system made up of bile pigments or hardened cholesterol cholesterol stones are more common stone formation occurs when the bile crystallizes contributing factors include stasis of bile in the gallbladder and bile concentration 3 Cholelithiasis : Cholelithiasis 4 Risk factors for cholelithiasis : Risk factors for cholelithiasis Age Family history of gallstones Race or ethnicity; Gender Diseases or conditions cirrhosis, ileal disease, sickle-cell anemia, hyperlipidemia, obesity and rapid weight loss, DM Biliary stasis Oral contraceptives with high estrogen content 5 Manifestations of Cholelithiasis : Manifestations of Cholelithiasis Stones in cystic duct severe, cramplike, colicky pain right upper abd pain nausea vomiting Obstruction of CBD jaundice pain hepatic damage pancreatitis sepsis clay colored stools 6 Manifestations of Cholelithiasis continued : Manifestations of Cholelithiasis continued Epigastric pain Heartburn Right upper abdominal pain (may radiate to subscapular area) Intolerance to fat-containing foods Jaundice 7 Cholecystitis : Cholecystitis Inflammation of the gallbladder Most commonly associated with stones in the cystic or CBD 5% of cases are acalculous may be related to trauma, hyperalimentation, extended fasting, surgery 8 Manifestations of Cholecystitis : Manifestations of Cholecystitis Acute severe spasmodic pain (usually initiated by high-fat meal) N&V low-grade fever jaundice Chronic long-term intolerance to fatty foods vague gastric symptoms flatulence 9 Additional manifestations of Cholecystitis : Additional manifestations of Cholecystitis High WBC count Abd muscle guarding with rebound tenderness and rigidity (may indicate peritoneal involvement) Elevated serum bilirubin Elevated alkaline phosphatase Elevated serum amylase if pancreatic ducts are involved 10 Complications of chronic cholecystitis : Complications of chronic cholecystitis Gangrene and perforation with peritonitis Empyema Fistula formation Gallstone ilius causing SBO 11 Gangrenous gallbladder with stones : Gangrenous gallbladder with stones 12 Laboratory and Diagnostic Tests : Laboratory and Diagnostic Tests CBC Serum amylase and lipase Serum bilirubin levels Flat plate of abd Oral cholecystogram Ultrasound Gallbladder scans 13 Collaborative CarePharmacology : Collaborative CarePharmacology Dissolvers Agents used for palliative relief of symptoms antibiotics Questran narcotics 14 Collaborative CareDiet Therapy : Collaborative CareDiet Therapy Low-fat diet May need fat soluble vitamins Obese clients are encouraged to lose weight NPO if client has severe N&V &/or NGT 15 Collaborative CareSurgery : Collaborative CareSurgery Cholecystectomy open or laparascopic Chole with CBD exploration and T-tube insertion T-tube maintains patency of the duct and promotes bile passage while the edema decreases 16 T-tube : T-tube 17 Nursing Diagnoses : Nursing Diagnoses Pain Imbalanced Nutrition: Less Risk for Infection Others? 18 Cancer of the Gallbladder : Cancer of the Gallbladder Rare Primarily affects people over age 65 More women than men 95% of clients with primary CA of gallbladder die within one year despite radical and extensive surgical interventions 19 Cancer of the Gallbladder : Cancer of the Gallbladder Manifestations intense pain in RUQ (may be able to palpate mass) jaundice/ green color pruritis weight loss Metastasis via the blood, lymph system, or through direct extension; liver is most commonly affected 20 Hepatitis : Hepatitis Inflammation of the liver, usually caused by a virus Other causes include ETOH, toxins (drugs), cholestasis due to hepatobiliary disease. May be secondary to other systemic vial infections Underlying pathophysiology varies with different types of hepatitis 21 Slide 22: 22 Viral Hepatitis : Viral Hepatitis Hepatitis A transmitted by oral-fecal route contaminated food, water, shellfish, intimate contact with carriers of the virus Hepatitis B transmitted to parenteral innoculation with contaminated blood or blood products, sexually transmitted disease 23 Manifestations of Hepatitis : Manifestations of Hepatitis Preicteric phase mimics influenza malaise, GI complaints including N&V, diarrhea, anorexia headache, fatigue, fever myalgia, polyarthritis sore throat, elevated LFTs right upper abd pain upon palpation 24 Manifestations of Hepatitis : Manifestations of Hepatitis Icteric phase jaundice of skin, sclera, and mucous membranes pruritus light brown or clay colored stools tea-colored urine appetite increases, temperature returns to normal 25 Manifestations of Hepatitis : Manifestations of Hepatitis Posticteric phase lasts several weeks manifestations gradually improve serum bilirubin & enzymes decrease to normal hepatic pain decreases GI symptoms and weakness subside Energy levels increase 26 Laboratory and Diagnostic Tests : Laboratory and Diagnostic Tests Multiple antigen, antibody tests Liver enzymes Conjugated and unconjugated bilirubin Prothrombin time Liver biopsy Liver scan 27 PharmacologyPrevention - Vaccination : PharmacologyPrevention - Vaccination Hepatitis A vaccine – One dose usually gives immunity but two are recommended. Hepatitis B vaccination—Three doses recommended for nurses and at risk health care workers and infants 28 PharmacologyPostexposure Prophylaxis : PharmacologyPostexposure Prophylaxis Hepatitis A--single dose of IG given within 2 weeks after exposure Recommended for all persons with household or sexual contact with a person known to be infected with Hepatitis A 29 PharmacologyPostexposure Prophylaxis : PharmacologyPostexposure Prophylaxis Hepatitis B--HBIG for short term; HBV vaccine given concurrently for long-term immunity 30 Collaborative Care : Collaborative Care Bed rest as needed Standard precautions & meticulous hand-washing Contact isolation if incontinent of feces Adequate nutrition as tolerated - high calorie Avoidance of strenuous activity, ETOH, and agents that are toxic to the liver 31 Nursing Diagnoses : Nursing Diagnoses Risk for Infection (Transmission) Fatigue Imbalanced Nutrition: Less Disturbed Body Image Others Knowledge Deficit Pain Risk for FVD 32 Cirrhosis of the Liver : Cirrhosis of the Liver Chronic disease that results in extensive hepatocellular damage Liver parenchyma is destroyed, regenerates, and eventually becomes scarred and fibrotic Loss of liver function occurs Systemic effects on the body Manifestations are r/t extent of liver damage 33 Manifestations of CirrhosisPortal hypertension : Manifestations of CirrhosisPortal hypertension Blood is rerouted to adjoining vessels that normally have lower BP than the portal vein Affected veins in the esophagus, rectum, and abdomen become engorged and congested Contributes to hydrostatic pressure ascites 34 Portal Venous System : Portal Venous System 35 Slide 36: 36 Manifestations of CirrhosisSplenomegly : Manifestations of CirrhosisSplenomegly Occurs in client with portal HTN as a result of the shunting of blood into the splenic vein Can result in hematological disorders such as anemia, thrombocytopenia, and leukopenia 37 Manifestations of CirrhosisAscites : Manifestations of CirrhosisAscites Accumulation of plasma-rich fluid in the peritoneal cavity serum proteins and aldosterone contribute to fluid accumulation Anasarca - generalized edema 38 Ascites : Ascites 39 Manifestations of CirrhosisEsophageal Varices : Manifestations of CirrhosisEsophageal Varices Enlarged, overdistended veins formed when portal venous system is congested and collateral veins become engorged with venous blood Clients are at risk for bleeding even high-roughage foods can precipitate bleeding thrombocytopenia contributes to increased risk of bleeding 40 Manifestations of CirrhosisHepatic Encephalopathy : Manifestations of CirrhosisHepatic Encephalopathy Accumulation of toxic substances (ammonia and others) in the circulation causes cognitive and motor changes Asterixis (early sign), then changes in personality and mentation occur Coma is final stage Process can be reversed or improved by body’s nitrogenous waste load 41 Laboratory and Diagnostic Tests : Laboratory and Diagnostic Tests Serum electrolytes & glucose, CBC Bilirubin levels, LFTs Total protein, serum albumin Ammonia levels, Coagulation studies Ultrasound Esophagoscopy Liver biopsy 42 Collaborative CarePharmacology : Collaborative CarePharmacology Diuretics Aldactone, Lasix Lactulose and Neomycin Vitamin K Antacids Avoid medications metabolized by the liver--barbituates, sedatives, hypnotics, Acetaminophen 43 Collaborative CareTreatments : Collaborative CareTreatments Sclerotherapy for esophageal varices Paracentesis Gastric lavage Balloon Tamponade Peritoneovenous shunt LeVeen shunt TIPS shunt (pg 593) Liver transplantation 44 Collaborative CareNutritional Considerations : Collaborative CareNutritional Considerations Restrict sodium intake Fluid restriction Dietary protein adjusted to client’s ability to handle the nitrogenous load High calorie, moderate fat intake during healing process Vitamin and mineral supplements 45 Nursing Diagnoses : Nursing Diagnoses Excess Fluid Volume Disturbed Thought Processes Ineffective Protection (bleeding) Impaired Skin Integrity Imbalanced Nutrition: Less Others- Risk for Infection Knowledge Deficit 46 Cancer of the Liver : Cancer of the Liver Primary hepatic CA uncommon in US Metastasizes to the liver from pulmonary, breast, and GI tract Poor prognosis 47 Causes of Primary Hepatic CA : Causes of Primary Hepatic CA Chronic Hepatitis B or C infection Chronic cirrhosis, regardless of type Chronic aflatoxin Arsenic contaminated water Hepatocarcinogenic pesticides in foods Hormonal factors Prolonged androgen therapy Contraceptive steroids 48 Manifestations of primary hepatic CA : Manifestations of primary hepatic CA Malaise, Lethargy Painful mass in RUQ Fullness in epigastric region Weight loss Anorexia FUO Signs of hepatic failure 49 Collaborative Care : Collaborative Care Partial hepatectomy single lesions without extrahepatic manifestations Liver transplantation RT Chemotherapy Chemoembolization 50 Nursing care : Nursing care Similar to care for patients with cirrhosis Avoid alcohol Pain control 51 Acute Pancreatitis : Acute Pancreatitis Inflammatory disorder that results in self-destruction of the pancreas by its own enzymes through autodigestion More common in middle adults Higher incidence in men than women Most often associated with gallstones in women and alcoholism in men 52 Factors that activate pancreatic enzymes : Factors that activate pancreatic enzymes Obstruction by a gallstone Obstruction of bile ducts Contents of duodenum (with activated pancreatic enzymes) back up into pancreas Excess HCl causes spasms of sphincter of Oddi and ampulla of Vater, obstructing pancreatic fluid flow 53 Pancreatitis secondary to choleliathesis : Pancreatitis secondary to choleliathesis 54 Pancreatitis secondary to choleliathesis : Pancreatitis secondary to choleliathesis 55 Factors associated with acute pancreatitis : Factors associated with acute pancreatitis Trauma or surgery Pancreatic tumors Third-trimester pregnancy Infectious agents Elevated calcium levels Hyperlipidemia Certain medications 56 Pathophysiology of acute pancreatitis : Pathophysiology of acute pancreatitis Release of pancreatic enzymes into the pancreatic tissue In hemorrhagic pancreatitis, enzymes cause fat necrosis of acinar cells and blood vessels large volume of fluid may shift from the circulating blood volume 57 Manifestations of acute pancreatitis : Manifestations of acute pancreatitis Continuous severe epigastric and abdominal pain N&V Abd distention and rigidity Decreased bowel sounds Signs of hypovolemic shock Mild jaundice may appear within 24 hr 58 Complications of acute pancreatitis : Complications of acute pancreatitis Development of DM Tetany Hypovolemic shock Pancreatic pseudocyst Abscess formation Peritonitis 59 Complications of acute pancreatitis : Complications of acute pancreatitis pleural effusion ARDS MODS renal failure ascites cardiac failure death 60 Chronic Pancreatitis : Chronic Pancreatitis Progressive disease that causes normal pancreatic tissue to be replaced by connective tissue Irreversible process that leads to pancreatic insufficiency Higher incidence in people aged 40-60 May follow acute pancreatitis or have no identifiable cause 61 Chronic Pancreatitis : Chronic Pancreatitis Recurrent episodes of inflammation eventually lead to changes in parenchyma loss of exocrine and endocrine functions malabsorption from pancreatic insufficiency DM from inability to produce insulin 62 Manifestations of chronic pancreatitis : Manifestations of chronic pancreatitis Upper abd pain radiating to the back N&V with weight loss Flatulence and constipation Steatorrhea Manifestations of malabsorption, DM Elevated serum and urinary amylase Elevated serum bilirubin 63 Laboratory and Diagnostic Tests : Laboratory and Diagnostic Tests Ultrasound CT scan ERCP Endoscopic ultrasonography Percutaneous fine-needle aspiration biopsy 64 Collaborative CarePharmacology : Collaborative CarePharmacology Demerol Antacids H2 blockers Proton pump inhibitors Antispasmodics Pancreatic enzyme supplements, insulin (chronic pancreatitis) 65 Collaborative CareDietary management : Collaborative CareDietary management NPO (insertion of NGT) TPN or IV fluids Oral food and fluids are begun once the serum amylase levels have returned to normal, bowel sounds are present, and pain disappears begins clear liquids and progresses to a low-fat diet as tolerated 66 Collaborative CareSurgery : Collaborative CareSurgery Endoscopic transduodenal sphincterotomy Cholecystectomy Surgical resection of pancreas to remove necrotic tissue Percutaneously inserted tubes to drain pseudocyst or abscess 67 Nursing Diagnoses : Nursing Diagnoses Pain Risk for Altered Nutrition: Less Risk for FVD Ineffective Breathing Pattern Risk for Infection Impaired Gas Exchange Altered Health Management Knowledge Deficit 68 Pancreatic Cancer : Pancreatic Cancer More common in adults over 50 Lethal- 98% with pancreatic CA die Incidence is higher in women than men and higher in African Americans than Caucasians Most occur in exocrine pancreas, are adenocarcinomas, and cause death in 1-3 years after diagnosis 69 Risk factors for Pancreatic CA : Risk factors for Pancreatic CA MAJOR RISK FACTOR IS SMOKING incidence is twice as high in smokers than nonsmokers Exposure to industrial chemicals or environmental toxins High-fat diet Pancreatitis DM 70 Manifestations of Pancreatic CA : Manifestations of Pancreatic CA Anorexia, nausea, weight loss, flatulence Dull epigastric pain that increases in severity as the tumor grows Late manifestations include palpable abdominal mass and ascites 71 Anatomy : Anatomy 72 Manifestations of Pancreatic CA : Manifestations of Pancreatic CA Head--jaundice, clay-colored stools, dark urine, pruritis Body--pain that increases when the person eats or lies supine Tail--no symptoms until it has metastasized 73 Collaborative Care : Collaborative Care Whipple’s procedure RT Chemotherapy Nursing Diagnoses?? 74 Slide 75: 75