Care of Patients with Disorders of the Gallbladder,
Liver, and Pancreas
Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc.
Theory Objectives
 Explain the plan of care for the patient with
cholelithiasis.
 Describe treatment for the patient with cholecystitis.
 List the ways in which the various types of hepatitis
can be transmitted.
 Identify signs and symptoms of the various types of
hepatitis.
1
Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc.
Theory Objectives (cont.)
 Devise appropriate nursing interventions for the
patient with cirrhosis and ascites.
 Indicate potential causes of liver failure.
 Differentiate the signs and symptoms of acute and
chronic liver failure.
 Describe the postoperative care of the patient who has
undergone a liver transplantation.
2
Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc.
Theory Objectives (cont.)
 Devise a nursing care plan for the patient with cancer
of the liver.
 Prepare a plan for adequate pain control for the patient
with pancreatitis.
 Compare the treatment options for cancer of the
pancreas.
3
Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc.
Clinical
Practice
Objectives
 Perform preoperative teaching for a patient who is to
undergo laparoscopic cholecystectomy.
 Write a nursing care plan, including psychosocial
concerns, for the patient who has hepatitis with
jaundice.
 Design a discharge teaching plan for the patient who
has been in the hospital with a flare-up of chronic
pancreatitis.
4
Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc.
Cholelithiasis and Cholecystitis
 Etiology
 Ethnic predisposition to gallstones
 Pathophysiology
 Signs and symptoms
 None to severe and unbearable pain
 Chronic cholecystitis is biliary colic
5
Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc.
Gallstones
6
Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc.
Cholelithiasis and Cholecystitis
 Diagnosis
 Ultrasonography
 Computed tomography (CT)
 Endoscopic retrograde cholangiopancreatography
(ERCP)
 Cholescintigraphy (hepatoiminodiacetic acid [HIDA]
scan)
 Liver function tests
7
Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc.
Comparison of Symptoms of
Gallbladder Disorders
 Pain/biliary colic
 Nausea, vomiting
 Indigestion and flatulence
 Low-grade fever
 Jaundice
8
Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc.
Cholelithiasis and Cholecystitis
 Treatment
 Diet
 Correction of bile obstruction
 Antibiotics
 Post-cholecystectomy diet
 Surgery
 Complications
9
Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc.
Postoperative Laparoscopic
Cholecystectomy
 Remove the bandages from the puncture sites the day
after surgery and shower
 Report the following signs and symptoms should they
occur: redness, swelling, bile-colored drainage or pus
from any surgical site, severe abdominal pain, nausea,
vomiting, chills, or fever, light-colored stool, dark
urine, or yellow tint to the eyes or skin, as these signs
may indicate obstruction of the flow of bile
10
Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc.
Postoperative Laparoscopic
Cholecystectomy (cont.)
 Normal activities may be resumed gradually
 Return to work is probable at 1 week postsurgery
 Stick to a low-fat diet for several weeks, slowly
introduce fattier foods to determine if these cause
unpleasant symptoms
11
Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc.
Nursing Management
 Preoperative care
 Postoperative care
 Caring for a T-tube
12
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T-Tube
13
Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc.
Hepatitis
 Etiology and pathophysiology
 Types of viral hepatitis
 HBV among Asian Americans
 Signs and symptoms
 Pre-icteric phase
 Icteric phase
 Post-icteric phase
 Complications
14
Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc.
Comparison of Hepatitis-Causing
Viruses
 Transmission modes
 Incubation periods
 Infective periods
 Signs and symptoms
15
Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc.
Diagnosis of Hepatitis
 Serologic assays or enzyme immunoassays (EIAs)
 Liver biopsy
 Elevations in liver function tests (LFTs)
16
Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc.
Laboratory Tests
 Aspartate aminotransferase (AST)
 Alanine aminotransferase (ALT)
 Gamma-glutamyl transpeptidase (GGT)
 Bilirubin
 Alkaline phosphatase
 Serum albumin
 Serum bilirubin (total)
 Prothrombin time
17
Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc.
Treatment of Hepatitis
 There is no specific treatment for acute viral hepatitis
 Non-drug measures include well-balanced diet and
rest, avoiding hepatotoxic substances including
alcohol and certain medications
 Active and passive immunity
 Antiviral therapy
18
Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc.
Expected Outcomes
 Patient will maintain body weight within normal
limits during illness
 Patient will verbalize lessened fatigue after rest periods
each day
 Patient will verbalize a decrease in pain after
institution of nursing measures to decrease
discomforts
19
Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc.
Expected Outcomes (cont.)
 Patient will verbalize knowledge of disease process and
self-care within 2 days
 Patient will engage in appropriate diversional activities
during convalescence
20
Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc.
Nursing Interventions
 Monitor progress
 Prevent the spread of infection
 Patient/family teaching—proper handling of body
secretions, proper hand hygiene, and limiting contact
 Psychological support
 Ensure adequate nutrition
21
Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc.
Prevention of Hepatitis
 Home considerations for different types of viral
hepatitis
 Standard Precautions guidelines
 Infection control
22
Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc.
Cirrhosis
 Etiology
 Postnecrotic cirrhosis
 Laënnec’s cirrhosis or portal cirrhosis
 Biliary cirrhosis
 Cardiac cirrhosis
 Liver-related deaths
23
Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc.
Cirrhosis
(cont.)
 Diagnosis
 Liver biopsy
 Liver function studies
 CT and liver scan
 Magnetic resonance cholangiopancreatography
 Treatment—stopping the liver damage and restoring
the liver’s functions
24
Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc.
Signs and Symptoms
 Subjective symptoms
 Fatigue
 Weakness
 Headache
 Anorexia
 Indigestion
 Abdominal pain
 Nausea
 Vomiting
25
Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc.
Signs and Symptoms (cont.)
 Fluid retention in the right hemithorax or ascites can




limit expansion of the chest and cause dyspnea
Objective symptoms of liver cirrhosis include excessive
gas, skin rashes, itching, and fever
Leg and foot edema and palmar erythema
Caput medusa
Bleeding and bruising
26
Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc.
Signs and Symptoms (cont.)
 Deficiencies in vitamin K, thrombin, or prothrombin
interfere with clot formation
 The liver often is enlarged and “knobby” and is
palpable below the level of the right rib cage
 Abdominal distention
 The spleen also enlarges
27
Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc.
Signs and Symptoms (cont.)
 Peripheral edema and ascites
 Skin lesions, jaundice, pruritus, bleeding disorders,
endocrine disorders, and peripheral neuropathy occur
in late disease
 Spider angiomas may appear on the face, neck, upper
trunk, and arms
 The angiomas may blanch with pressure
28
Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc.
Signs and Symptoms of Cirrhosis
29
Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc.
Relationship of Systemic Portal
Hypertension and Ascites in
Cirrhosis
30
Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc.
Nursing Management of Cirrhosis
 Assessment
 Assess for safety issues
 Laboratory tests
 Alcohol withdrawal
 Nursing diagnosis
 Planning and implementation
 Evaluation
31
Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc.
Complications of Cirrhosis
 Esophageal varices
 Encephalopathy
 Delirium, convulsions, asterixis, and coma
 Fetor hepaticus
32
Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc.
Blakemore-Sengstaken Tube
33
Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc.
Liver Transplantation
 Legal and ethical considerations
 Nursing management
 Care of drains
 Immunosuppressants
 Liver function monitoring
34
Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc.
Cancer of the Liver
 Etiology
 Pathophysiology
 Signs and symptoms
 Diagnosis
 Treatment
 Nursing management
35
Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc.
Acute Pancreatitis
 Etiology
 Pathophysiology
 Signs and symptoms
 Diagnosis
 Treatment
 Nursing management
36
Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc.
Chronic Pancreatitis
 Etiology and pathophysiology
 Signs and symptoms
 Diagnosis
 Determination of bicarbonate concentration and output
in the duodenum after stimulation with secretin is the
definitive test for chronic pancreatitis
37
Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc.
Chronic Pancreatitis (cont.)
 Treatment
 Nursing management
 Pain management
 Complications including diabetes mellitus
 Avoid alcohol
38
Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc.
Pathophysiology of Acute
Pancreatitis
39
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Cancer of the Pancreas
 Etiology
 Pancreatic cancer deaths
 Healthy gums for better pancreatic health
 Pathophysiology
 Cigarette smoking
 Adenocarcinoma
 Tumor in the head of the pancreas
 Tumor in the body and tail of pancreas
40
Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc.
Cancer of the Pancreas (cont.)
 Signs and symptoms
 Deep vein thrombosis
 Diagnosis
 Ultrasonography, imaging techniques, and fine-needle
biopsy
 Elevated carcinoembryonic antigen levels
 Serum beta-human chorionic gonadotropin and
carbohydrate antigen (CA) 72-4
 Tumor markers CA 19-9 and CA 242
41
Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc.
Cancer of the Pancreas (cont.)
 Treatment
 Keep the patient comfortable
 Treat or prevent malnutrition
 Surgical treatment including Whipple procedure, or
radical pancreaticoduodenectomy
 Other treatments
 Nursing management
 Community care
42
Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc.
Audience
Response
Question
1
The nurse caring for a patient who has undergone
radical pancreaticoduodenectomy should monitor for
which postoperative complication(s)? (Select all that
apply.)
1. Hypoglycemia
2. Hemorrhage
3. Bowel obstruction
4. Intra-abdominal abscess
5. Hyperkalemia
43
Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc.