AFAMS Master Lesson Plan (MLP)
Nursing Program
Introduction to the Gallbladder, Liver, and Exocrine Pancreas
Instructor
Serial/Semester
Location
Start/Finish Time
Date
LESSON OBJECTIVE
Performance: To gain an understanding of the gallbladder, liver, and exocrine pancreas.
Conditions:
The student will be presented a powerpoint presentation by the instructor and will have
all necessary references made available to him/her.
Standard:
1.
Given the five elements of the nursing care process and a scenario of a patient in a
clinical setting with a disorder of the gallbladder, liver, biliary tract or exocrine
pancreas by correctly responding to written, oral, and experiential assessment
measures
TEACHING POINTS
1. Define key terms related to the hepatobiliary
system.
2. Identify the structure and function of the
organs in the hepatobiliary system.
3. Identify laboratory and diagnostic
examinations used in the diagnosis of the
liver, gallbladder and exocrine pancreas
disorders and the appropriate nursing
interventions related to these tests.
4.
5.
6.
7.
8
9.
10.
INSTRUCTIONAL STRATEGY
Interactive Lecture
Method:
Instructor
Media:
Classroom
Environment:
OTHER LESSON SPECIFICATIONS
Knowledge Lesson
Type of Lesson:
1/50
Ratio:
Resources:
.
LESSON PLAN APPROVAL
End of Lesson Test: None
Minutes
Instructional Time: 162
Reference(s):
ISBN 0-323-01728-2
Adult Health Nursing, 4th Edition
01 Jan 2003
ISBN 0-7817-3553-X
Introductory Medical-Surgical Nursing, 8th Edition
01 Jan 2002
AFAMS Master Lesson Plan (MLP)
Nursing Program
Introduction to the Gallbladder, Liver, and Exocrine Pancreas
Signature of Standards Officer
1
Date
AFAMS Master Lesson Plan (MLP)
Nursing Program
Introduction to the Gallbladder, Liver, and Exocrine Pancreas
INTRODUCTION
Allocated Time:
Review:
5 Minutes
You have had previous anatomy and physiology lectures in your combat medic
training, this lecture will build upon prior instruction.
Objective:
To discuss/describe topics related to the nursing process.
Importance:
Nurses work in various health care settings so it is important to gain an
understanding of this subject as it will apply to your clinical practice.
Fit:
There are a number of diagnostic tests that the doctor will use to assess the
function of the liver, gallbladder, and exocrine pancreas. Many of these tests
are invasive and frightening to the patient. As a licensed vocational nurse, you
will play an important role in preparing the patient and family for these tests
and monitoring them after the tests are completed.
Approach:
You will be presented the subject in lecture format and will be tested using a
written exam at a later date.
Control Statement:
If you have any questions during the lesson please feel free to ask.
BODY
1. Teaching Point: Define key terms related to the hepatobiliary system.
Minutes
Allocated Time:
Introduction:
Learner Participation:
Knowledge Lesson Please follow along with your hand outs and take notes.
Skill Lesson
Powerpoint presentation with associated handouts.
Learning Support:
a. Cholang --- Pertaining to bile ducts.
b. Cholangiography --- X-ray examination of the bile duct.
c. Choledocho --- Pertaining to common bile duct.
d. Choledocholithiasis --- Stones in the common bile duct.
e. Cirrhosis --- A chronic degenerative disease of the liver.
f. Hepatitis --- Inflammation of the liver.
g. Hepatomegaly --- Enlargement of the liver.
h. Asterixis --- A hand flapping tremor.
i. Esophageal varices --- A complex of longitudinal, tortuous veins at the lower end of the esophagus.
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AFAMS Master Lesson Plan (MLP)
Nursing Program
Introduction to the Gallbladder, Liver, and Exocrine Pancreas
j. Hepatic Encephalopathy --- A type of brain damage caused by liver disease and consequent ammonia
intoxication.
k. Paracentesis --- A procedure in which fluid is withdrawn from the abdominal cavity.
l. Parenchyma --- Tissue of an organ as distinguished from supporting or connective tissue.
m. Flatulence --- Excess formation of gases in the stomach.
n. Ascites --- Abnormal intraperitoneal accumulation of fluid and albumin.
o. Pruritus --- The symptom of itching.
Knowledge Lesson:
Question:
Answer:
Check on Learning
In a knowledge lesson, pose questions to the class.
A hand-flapping tremor associated with liver disease is called?
Asterexis.
Skill Lesson:
In a skill lesson, provide practice and watch students perform a skill.
2. Teaching Point: Identify the structure and function of the organs in the hepatobiliary system.
Minutes
Allocated Time:
Introduction:
Learner Participation:
Knowledge Lesson Please follow along with your hand outs and take notes.
Skill Lesson
Powerpoint presentation with associated handouts.
Learning Support:
a. Liver.
(1) Largest and one of the most complex glandular organs in the body.
(2) Located just inferior to the diaphragm, covering most of the right upper quadrant and extending
into the left epigastrium.
(3) Divided into two lobes.
(4) Receives approximately 1500 ml/minute of blood via the portal vein and hepatic artery.
(5) Hepatocytes (cells of the liver) produce bile.
(a) Bile is necessary for the metabolism of fats.
(b) Bile travels through the hepatic duct to the gall bladder for storage.
(6) Functions.
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AFAMS Master Lesson Plan (MLP)
Nursing Program
Introduction to the Gallbladder, Liver, and Exocrine Pancreas
(a) Metabolizes fats.
(b) Manages blood coagulation and produces most of the clotting factors (in the presence of Vitamin
K).
(c) Manufactures cholesterol.
(d) Manufactures albumin (maintains normal blood volume).
(e) Filters out old red blood cells and bacteria.
(f) Detoxifies poisons (alcohol, nicotine, drugs).
(g) Converts ammonia to urea.
(h) Provides the main source of body heat.
(i) Stores glycogen for later use.
(j) Activates Vitamin D.
(k) Breaks down nitrogenous wastes to urea.
b. Gall bladder.
(1) Sac about 3 to 4 inches long located on the right inferior surface of the liver.
(2) Stores bile needed for fat digestion.
c. Pancreas.
(1) Elongated gland that lies posterior to the stomach.
(2) Involved in both exocrine and endocrine function.
(3) Produces 1000 to 1500 ml of pancreatic juice daily to aid in digestion.
(4) Digests the three major components of chyme: proteins, fats and carbohydrates.
(5) Contents of pancreatic juice.
(a) Protease (Trypsin).
(b) Lipase (Steapsin).
(c) Amylase (Amylopsin).
(6) Enzymes are transported to the duodenum via the pancreatic duct to the common bile duct and out
to the duodenum via the papilla of Vater.
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AFAMS Master Lesson Plan (MLP)
Nursing Program
Introduction to the Gallbladder, Liver, and Exocrine Pancreas
(7) Also contains sodium bicarbonate, an alkaline substance that has the ability to neutralize the
hydrochloric acid in the gastric juices that enter the small intestine from the stomach.
d. The liver, gallbladder and exocrine pancreas all play an important role in digestion.
e. The biliary system is comprised of the organs and duct system that create, transport, store and release
bile into the duodenum for digestion. It includes the liver, gallbladder and bile ducts (named the cystic,
hepatic, common, and pancreatic duct).
Knowledge Lesson:
Question:
Answer:
Check on Learning
In a knowledge lesson, pose questions to the class.
What two functions does the pancreas have?
Exocrine and endocrine
Skill Lesson:
In a skill lesson, provide practice and watch students perform a skill.
3. Teaching Point: Identify laboratory and diagnostic examinations used in the diagnosis of the liver,
gallbladder and exocrine pancreas disorders and the appropriate nursing interventions related to
these tests.
Minutes
Allocated Time:
Introduction:
Learner Participation:
Knowledge Lesson Please follow along with your hand outs and take notes.
Skill Lesson
Powerpoint presentation with associated handouts.
Learning Support:
a. Laboratory Studies: Used in the Assessment of the Liver and gallbladder disorders.
(1) Serum bilirubin test. Normal values are as follows:
(a) Direct bilirubin: 0.1-0.3 mg/dl.
(b) Indirect bilirubin: 0.2-0.8 mg/dl.
(c) Total bilirubin 0.1-1.0 mg/dl.
(d) Rationale: Assess liver function. Elevated levels will cause jaundice, which is the most common
sign of a liver disorder (Timby).
1) Old red blood cells are broken down by the spleen and bone marrow. The hemoglobin which is
released is converted into indirect bilirubin. This bilirubin is carried by the blood to the liver, where it is
converted to direct bilirubin. The bilirubin then enters the bile ducts and makes its way to the intestines.
2) Measures both direct or conjugated (water soluble) and indirect or unconjugated (waterinsoluble) bilirubin. Total serum bilirubin level is the sum of the direct and indirect bilirubin levels.
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AFAMS Master Lesson Plan (MLP)
Nursing Program
Introduction to the Gallbladder, Liver, and Exocrine Pancreas
3) Testing for bilirubin in the blood provides information for diagnosis and evaluation of liver
disease, biliary obstruction and hemolytic anemia.
(e) Nursing interventions: Keep patient NPO until blood specimen is drawn. Monitor venipuncture
site for bleeding. Apply pressure for 5 minutes if patient has a problem with clotting.
(2) Liver enzymes tests.
(a) AST (Aspartate aminotransferase) formerly serum SGOT.
1) Normal value: Adult 5 to 40 IU/L.
2) Elevated in myocardial infarction, hepatitis, cirrhosis, hepatic necrosis, hepatic tumor, acute
pancreatitis, acute renal disease, and acute hemolytic anemia.
(b) ALT (Alanine aminotransferase) formerly SGPT.
1) Normal value: Adults/child 5 to 35 IU/L.
2) Elevated in hepatitis, cirrhosis, hepatic necrosis, and hepatic tumors and by hepatotoxic drugs.
(c) LDH (Lactic dehydrogenase).
1) Normal value: 45 to 90 U/L, 115 to 225 IU/L.
2) Elevated in myocardial infarction, pulmonary infarction, hepatic disease, pancreatitis, hemolytic
anemia and skeletal muscle disease.
(d) Alkaline phosphatase.
1) Normal value: Adult 30 to 85 ImU/ml.
2) Elevated in obstructive disorders of the biliary tract, hepatic tumors, cirrhosis, primary and
metastatic tumors, hyperparathyroidism, metastatic tumor in bones, and healing fractures.
(e) Gamma GT (Gamma glutamyltransferase).
1) Normal value: Male/female over 45: 8 to 8 U/L; female under 45: 5-27 U/L.
2) Elevated in liver cell dysfunction: hepatitis, cirrhosis, hepatic tumors, hepatotoxic drugs,
myocardial infarction, congestive heart failure, and alcohol ingestion.
(f) Rationale: The liver is a storehouse of enzymes. Injury or disease will cause release of these
intracellular enzymes into the bloodstream and their levels will be elevated. Some of these enzymes are
produced in other organs so elevations may not be specific to the liver.
(g) Nursing interventions: Patient teaching, assess site for bleeding.
(3) Prothrombin time:
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AFAMS Master Lesson Plan (MLP)
Nursing Program
Introduction to the Gallbladder, Liver, and Exocrine Pancreas
(a) Normal value: 11.0-12.6 sec.
(b) Rationale: Detects increased clotting time that can occur from liver disease (inability to
synthesize clotting factors) or vitamin K deficiency.
(c) Nursing interventions: Same as for bilirubin.
(4) Serum Protein Test: Normal values.
(a) Total protein: 6 to 8 g/dl.
(b) Albumin: 3.2 to 4.5 g/dl.
(c) Globulin: 2.3 to 3.4 g/dl.
(d) Albumin globulin (A/G ration) 1.2 to 2.2 g/dl.
(e) Rationale:
1) Can assess functional status of liver by measuring the products that are synthesized there:
protein, especially albumin.
2) With liver disease hepatocytes lose the ability to synthesize albumin so levels decrease.
3) Low levels may also result from excessive loss of albumin into the urine (nephrotic syndrome),
into the third space (ascites), or protein deplete nutrition.
(f) Nursing interventions: Patient education. Assess site for bleeding.
(5) Serum ammonia.
(a) Normal value 15-110 ug/dl.
(b) Rationale: Byproduct of protein metabolism is converted by liver to urea and excreted by
kidneys. In liver dysfunction, serum ammonia level increases and BUN level decreases. Used in
diagnosis of hepatic encephalopathy or coma.
(c) Nursing interventions: List antibiotics patient is taking on lab request as they may affect results.
b. Radiographic studies.
(1) Oral Cholecystography.
(a) Rationale: Provides visualization of the gallbladder after ingestion of radiopaque contrast.
Requires concentration of the dye within the gallbladder. Patient must take dye tablets evening prior to
test. Vomiting or diarrhea will cause decreased absorption and affect results.
(b) Nursing interventions.
1) Interview patient and review medical records to rule out allergy to iodine/contrast medium.
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AFAMS Master Lesson Plan (MLP)
Nursing Program
Introduction to the Gallbladder, Liver, and Exocrine Pancreas
2) Administer radiopaque tablets as ordered.
3) NPO after midnight.
4) May be given high fat diet after test has started to stimulate emptying of the gallbladder.
(2) Intravenous cholangiography (IVC).
(a) Rationale: Radiographic dye, injected intravenously, is concentrated by the liver and secreted
into the bile duct. IVC allows visualization of hepatic and common bile ducts and gallbladder if cystic
duct is patent. Used to identify stones, stricture, or tumor of the hepatic duct, common bile duct, and
gallbladder.
(b) Nursing interventions: Same as above, except tablets are not given.
(3) Operative cholangiography.
(a) Common bile duct is injected with dye. Allows surgeon to view this anatomically difficult area
before interventions to decrease chance of injuring common bile duct.
(b) Nursing interventions: Same as above.
(4) T-tube cholangiography (Postoperative cholangiography).
(a) Rationale.
1) Performed to identify retained stones in the postoperative cholecystectomy patient.
2) Performed via a T-tube placed by the surgeon intra-operatively.
3) Contrast is injected to ensure adequate flow of bile into the duodenum.
(b) Nursing interventions.
1) Protect the patient from infection by connecting tube to sterile drainage system.
2) Cover with sterile dressing.
3) NPO after midnight.
(5) Gallbladder scanning.
(a) Rationale: Nuclear medicine scan with radioactive isotope used for the diagnosis of acute
cholecystitis.
(b) Nursing interventions.
1) Educate patient that the small dose of radiation used is harmless.
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AFAMS Master Lesson Plan (MLP)
Nursing Program
Introduction to the Gallbladder, Liver, and Exocrine Pancreas
2) NPO after midnight.
3) Encourage patient to drink fluids after test to promote excretion of the radionuclide.
4) Nursing staff should wear gloves when handling urine.
(6) Radioisotope Liver Scanning.
(a) Rationale: Used to outline and detect structural changes in liver. After contrast is injected,
gamma-ray device passed over abdomen. Records distribution of the radioactive particles in the liver.
(b) Nursing interventions: Same as above.
c. Other Imaging Procedures.
(1) Ultrasonography of Liver, Gallbladder, and Biliary System:
(a) Rationale: Imaging technique in which deep structures are visualized by recording the reflections
of ultrasonic waves directed into the tissues. Good for patient who is allergic to contrast.
(b) Nursing interventions.
1) NPO after midnight.
2) Check to see that patient has not had a recent barium enema. (ultrasound waves cannot
penetrate barium).
3) Explain to patient that they will be lying on a table, a technician will apply gel to the stomach
and move a transducer over the abdomen.
d. Tissue examination.
(1) Needle Liver Biopsy.
(a) Rationale: Safe, simple and valuable method to diagnose pathological liver conditions. Needle is
inserted through the skin, into intercostal space and into liver where tissue is removed. Used in the
diagnosis of cirrhosis, hepatitis, drug-related reactions, granuloma and tumor.
(b) Nursing interventions.
1) Explain procedure to patient and obtain informed consent.
2) Check lab values for coagulation studies.
3) Observe for bleeding after procedure. Monitor VS.
4) Assess for pain, provide analgesics as ordered.
5) Assess for pneumothorax.
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AFAMS Master Lesson Plan (MLP)
Nursing Program
Introduction to the Gallbladder, Liver, and Exocrine Pancreas
6) Keep patient lying on right side for 2 hours and flat for 12 to 14 hours.
(2) Endosopic Retrograde Cholangiopancreatography (ERCP).
(a) Rationale: Fiberoptic duodenoscope inserted through GI tract into duodenum. Common bile
duct and pancreatic duct are visualized after dye is injected. Used to diagnose pancreatic dysfunction.
Also used to evaluate obstructive jaundice, remove common bile duct stones, and place biliary and
pancreatic duct stents to bypass obstruction
(b) Nursing interventions.
1) NPO after midnight.
2) Educate patient and sign permit.
a) Test takes 1-2 hours to complete. Patient must lie completely motionless on a hard X-ray
table.
b) NPO post-procedure until gag reflex returns, assess for abdominal pain, tenderness and
guarding.
c) Assess for signs and symptoms of pancreatitis-increased abdominal pain, nausea, vomiting,
diminished or absent bowel sounds.
e. Laboratory tests related to the Pancreas.
(1) Amylase Test: Normal 25 to 125 U/L.
(a) Rationale: Test for pancreatitis. Abnormal serum rise occurs 12 hours after onset of pancreatic
disease. May return to normal within 48 to 72 hours. (Amylase is cleared efficiently by the kidneys).
(b) Nursing interventions:
NOTE: List medications on lab request due to false-positive results.
(2) Serum Lipase Test: Normal 0 to 110 U/L.
(a) Rationale: Elevated in acute pancreatitis. (More specific than amylase for pancreatitis).
(b) Nursing interventions: Keep patient NPO after midnight.
f. Imaging procedures for the pancreas.
(1) Ultrasonography of Pancreas.
(a) Rationale: Used to establish the diagnosis of pseudocyst, pancreatitis, and pancreatic abscess.
(b) Nursing interventions.
1) NPO after midnight.
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AFAMS Master Lesson Plan (MLP)
Nursing Program
Introduction to the Gallbladder, Liver, and Exocrine Pancreas
2) Assess abdomen for distention or gas that may interfere with sound waves.
(2) Computed Tomography (CT) of Abdomen.
(a) Rationale: Noninvasive accurate test used to diagnose pathological pancreatic conditions such as
inflammation, tumor, cyst formation, ascites, aneurysm, and cirrhosis of liver.
(b) Nursing interventions.
1) NPO after midnight.
2) Decrease patient's anxiety to claustrophobia from machine.
Knowledge Lesson:
Question:
Answer:
Check on Learning
In a knowledge lesson, pose questions to the class.
Click here to enter the question.
Click here to enter the answer.
Skill Lesson:
In a skill lesson, provide practice and watch students perform a skill.
END OF LESSON TEST
Allocated Time:
Instructions:
Test Questions or
Performance
Expected:
Test Key:
0 Minutes
You will be tested on this subject at a later date.
You will be expected to review and study the material taught in this session in
order to pass the associated written test. If you have difficulty with the material
please see me so we can review together.
None.
CONCLUSION
Allocated Time:
Summary:
5 Minutes
Review and re-emphasize the difficult Teaching Points below.
1.
2.
3.
4.
5.
6.
7.
8
9.
10.
11
Define key terms related to the hepatobiliary system.
Identify the structure and function of the organs in the hepatobiliary
system.
Identify laboratory and diagnostic examinations used in the diagnosis
of the liver, gallbladder and exocrine pancreas disorders and the
appropriate nursing interventions related to these tests.
AFAMS Master Lesson Plan (MLP)
Nursing Program
Introduction to the Gallbladder, Liver, and Exocrine Pancreas
Closing Statement:
Nurses work in various health care settings so it is important to gain an
understanding of this subject as it will apply to your clinical practice.
Re-motivating
Statement:
There are a number of diagnostic tests that the doctor will use to assess the
function of the liver, gallbladder, and exocrine pancreas. Many of these tests
are invasive and frightening to the patient. As a licensed vocational nurse, you
will play an important role in preparing the patient and family for these tests
and monitoring them after the tests are completed.
12