Chapter 44- Management of Patients with Biliary Disorders

25. A community health nurse is caring for a patient whose multiple health problems include chronic pancreatitis. During the most recent visit, the nurse notes that the patient is experiencing severe abdominal pain and has vomited 3 times in the past several hours. What is the nurse's most appropriate action? A) Administer a PRN dose of pancreatic enzymes as ordered. B) Teach the patient about the importance of abstaining from alcohol. C) Arrange for the patient to be transported to the hospital. D) Insert an NG tube, if available, and stay with the patient.

C) Arrange for the patient to be transported to the hospital. Feedback: Chronic pancreatitis is characterized by recurring attacks of severe upper abdominal and back pain, accompanied by vomiting. The onset of these acute symptoms warrants hospital treatment. Pancreatic enzymes are not indicated and an NG tube would not be inserted in the home setting. Patient education is a later priority that may or may not be relevant.

3. A patient's assessment and diagnostic testing are suggestive of acute pancreatitis. When the nurse is performing the health interview, what assessment questions address likely etiologic factors? Select all that apply. A) "How many alcoholic drinks do you typically consume in a week?" B) "Have you ever been tested for diabetes?" C) "Have you ever been diagnosed with gallstones?" D) "Would you say that you eat a particularly high-fat diet?" E) "Does anyone in your family have cystic fibrosis?"

A) "How many alcoholic drinks do you typically consume in a week?" C) "Have you ever been diagnosed with gallstones?" Feedback: Eighty percent of patients with acute pancreatitis have biliary tract disease such as gallstones or a history of long-term alcohol abuse. Diabetes, high-fat consumption, and cystic fibrosis are not noted etiologic factors.

37. A patient with ongoing back pain, nausea, and abdominal bloating has been diagnosed with cholecystitis secondary to gallstones. The nurse should anticipate that the patient will undergo what intervention? A) Laparoscopic cholecystectomy B) Methyl tertiary butyl ether (MTBE) infusion C) Intracorporeal lithotripsy D) Extracorporeal shock wave therapy (ESWL)

A) Laparoscopic cholecystectomy Feedback: Most of the nonsurgical approaches, including lithotripsy and dissolution of gallstones, provide only temporary solutions to gallstone problems and are infrequently used in the United States. Cholecystectomy is the preferred treatment.

24. An adult patient has been admitted to the medical unit for the treatment of acute pancreatitis. What nursing action should be included in this patient's plan of care? A) Measure the patient's abdominal girth daily. B) Limit the use of opioid analgesics. C) Monitor the patient for signs of dysphagia. D) Encourage activity as tolerated.

A) Measure the patient's abdominal girth daily. Feedback: Due to the risk of ascites, the nurse should monitor the patient's abdominal girth. There is no specific need to avoid the use of opioids or to monitor for dysphagia, and activity is usually limited.

27. A patient has a recent diagnosis of chronic pancreatitis and is undergoing diagnostic testing to determine pancreatic islet cell function. The nurse should anticipate what diagnostic test? A) Glucose tolerance test B) ERCP C) Pancreatic biopsy D) Abdominal ultrasonography

A) Glucose tolerance test Feedback: A glucose tolerance test evaluates pancreatic islet cell function and provides necessary information for making decisions about surgical resection of the pancreas. This specific clinical information is not provided by ERCP, biopsy, or ultrasound.

7. A patient has been scheduled for an ultrasound of the gallbladder the following morning. What should the nurse do in preparation for this diagnostic study? A) Have the patient refrain from food and fluids after midnight. B) Administer the contrast agent orally 10 to 12 hours before the study. C) Administer the radioactive agent intravenously the evening before the study. D) Encourage the intake of 64 ounces of water 8 hours before the study.

A) Have the patient refrain from food and fluids after midnight. Feedback: An ultrasound of the gallbladder is most accurate if the patient fasts overnight, so that the gallbladder is distended. Contrast and radioactive agents are not used when performing ultrasonography of the gallbladder, as an ultrasound is based on reflected sound waves.

4. A patient's abdominal ultrasound indicates cholelithiasis. When the nurse is reviewing the patient's laboratory studies, what finding is most closely associated with this diagnosis? A) Increased bilirubin B) Decreased serum cholesterol C) Increased blood urea nitrogen (BUN) D) Decreased serum alkaline phosphatase level

A) Increased bilirubin Feedback: If the flow of blood is impeded, bilirubin, a pigment derived from the breakdown of red blood cells, does not enter the intestines. As a result, bilirubin levels in the blood increase. Cholesterol, BUN, and alkaline phosphatase levels are not typically affected.

36. A patient with a cholelithiasis has been scheduled for a laparoscopic cholecystectomy. Why is laparoscopic cholecystectomy preferred by surgeons over an open procedure? A) Laparoscopic cholecystectomy poses fewer surgical risks than an open procedure. B) Laparoscopic cholecystectomy can be performed in a clinic setting, while an open procedure requires an OR. C) A laparoscopic approach allows for the removal of the entire gallbladder. D) A laparoscopic approach can be performed under conscious sedation.

A) Laparoscopic cholecystectomy poses fewer surgical risks than an open procedure. Feedback: Open surgery has largely been replaced by laparoscopic cholecystectomy (removal of the gallbladder through a small incision through the umbilicus). As a result, surgical risks have decreased, along with the length of hospital stay and the long recovery period required after standard surgical cholecystectomy. Both approaches allow for removal of the entire gallbladder and must be performed under general anesthetic in an operating theater.

How does the nurse assess the patient's fluid and electrolyte status? SATA A) Noting the skin turgor B) Noting moistness of mucous membranes C) Weighing the patient daily D) Carefully measuring fluid intake/output- including urine output, nasogastric secretions, and diarrhea. E) Increased body temperature F) Wound drainage G) Assessing abdominal girth if ascites is suspected H) Decreased body temperature

A) Noting the skin turgor B) Noting moistness of mucous membranes C) Weighing the patient daily D) Carefully measuring fluid intake/output- including urine output, nasogastric secretions, and diarrhea. E) Increased body temperature F) Wound drainage G) Assessing abdominal girth if ascites is suspected

6. A 37-year-old male patient presents at the emergency department (ED) complaining of nausea and vomiting and severe abdominal pain. The patient's abdomen is rigid, and there is bruising to the patient's flank. The patient's wife states that he was on a drinking binge for the past 2 days. The ED nurse should assist in assessing the patient for what health problem? A) Severe pancreatitis with possible peritonitis B) Acute cholecystitis C) Chronic pancreatitis D) Acute appendicitis with possible perforation

A) Severe pancreatitis with possible peritonitis Feedback: Severe abdominal pain is the major symptom of pancreatitis that causes the patient to seek medical care. Pain in pancreatitis is accompanied by nausea and vomiting that does not relieve the pain or nausea. Abdominal guarding is present and a rigid or board-like abdomen may be a sign of peritonitis. Ecchymosis (bruising) to the flank or around the umbilicus may indicate severe peritonitis. Pain generally occurs 24 to 48 hours after a heavy meal or alcohol ingestion. The link with alcohol intake makes pancreatitis a more likely possibility than appendicitis or cholecystitis.

9. A patient with chronic pancreatitis had a pancreaticojejunostomy created 3 months ago for relief of pain and to restore drainage of pancreatic secretions. The patient has come to the office for a routine postsurgical appointment. The patient is frustrated that the pain has not decreased. What is the most appropriate initial response by the nurse? A) "The majority of patients who have a pancreaticojejunostomy have their normal digestion restored but do not achieve pain relief." B) "Pain relief occurs by 6 months in most patients who undergo this procedure, but some people experience a recurrence of their pain." C) "Your physician will likely want to discuss the removal of your gallbladder to achieve pain relief." D) "You are probably not appropriately taking the medications for your pancreatitis and pain, so we will need to discuss your medication regimen in detail."

B) "Pain relief occurs by 6 months in most patients who undergo this procedure, but some people experience a recurrence of their pain." Feedback: Pain relief from a pancreaticojejunostomy often occurs by 6 months in more than 85% of the patients who undergo this procedure, but pain returns in a substantial number of patients as the disease progresses. This patient had surgery 3 months ago; the patient has 3 months before optimal benefits of the procedure may be experienced. There is no obvious indication for gallbladder removal and nonadherence is not the most likely factor underlying the pain.

35. A patient is admitted to the unit with acute cholecystitis. The physician has noted that surgery will be scheduled in 4 days. The patient asks why the surgery is being put off for a week when he has a "sick gallbladder." What rationale would underlie the nurse's response? A) Surgery is delayed until the patient can eat a regular diet without vomiting. B) Surgery is delayed until the acute symptoms subside. C) The patient requires aggressive nutritional support prior to surgery. D) Time is needed to determine whether a laparoscopic procedure can be used.

B) Surgery is delayed until the acute symptoms subside. Feedback: Unless the patient's condition deteriorates, surgical intervention is delayed just until the acute symptoms subside (usually within a few days). There is no need to delay surgery pending an improvement in nutritional status, and deciding on a laparoscopic approach is not a lengthy process.

32. A patient has just been diagnosed with chronic pancreatitis. The patient is underweight and in severe pain and diagnostic testing indicates that over 80% of the patient's pancreas has been destroyed. The patient asks the nurse why the diagnosis was not made earlier in the disease process. What would be the nurse's best response? A) "The symptoms of pancreatitis mimic those of much less serious illnesses." B) "Your body doesn't require pancreatic function until it is under great stress, so it is easy to go unnoticed." C) "Chronic pancreatitis often goes undetected until a large majority of pancreatic function is lost." D) "It's likely that your other organs were compensating for your decreased pancreatic function."

C) "Chronic pancreatitis often goes undetected until a large majority of pancreatic function is lost." Feedback: By the time symptoms occur in chronic pancreatitis, approximately 90% of normal acinar cell function (exocrine function) has been lost. Late detection is not usually attributable to the vagueness of symptoms. The pancreas contributes continually to homeostasis and other organs are unable to perform its physiologic functions.

21. A nurse is creating a care plan for a patient with acute pancreatitis. The care plan includes reduced activity. What rationale for this intervention should be cited in the care plan? A) Bed rest reduces the patient's metabolism and reduces the risk of metabolic acidosis. B) Reduced activity protects the physical integrity of pancreatic cells. C) Bed rest lowers the metabolic rate and reduces enzyme production. D) Inactivity reduces caloric need and gastrointestinal motility.

C) Bed rest lowers the metabolic rate and reduces enzyme production. Feedback: The acutely ill patient is maintained on bed rest to decrease the metabolic rate and reduce the secretion of pancreatic and gastric enzymes. Staying in bed does not release energy from the body to fight the disease.

28. A patient has been admitted to the hospital for the treatment of chronic pancreatitis. The patient has been stabilized and the nurse is now planning health promotion and educational interventions. Which of the following should the nurse prioritize? A) Educating the patient about expectations and care following surgery B) Educating the patient about the management of blood glucose after discharge C) Educating the patient about postdischarge lifestyle modifications D) Educating the patient about the potential benefits of pancreatic transplantation

C) Educating the patient about postdischarge lifestyle modifications Feedback: The patient's lifestyle (especially regarding alcohol use) is a major determinant of the course of chronic pancreatitis. The disease is not often managed by surgery and blood sugar monitoring is not necessarily indicated for every patient after hospital treatment. Transplantation is not an option.

Which is a clinical manifestation of cholelithiasis?

Clay-colored stools The client with gallstones has clay-colored stools and excruciating RUQ pain that radiates to the back or right shoulder. The excretion of bile pigments by the kidneys makes urine very dark. The feces, no longer colored with bile pigments, are grayish (like putty) or clay colored. The client develops a fever and may have a palpable abdominal mass.

16. A patient has been treated in the hospital for an episode of acute pancreatitis. The patient has acknowledged the role that his alcohol use played in the development of his health problem, but has not expressed specific plans for lifestyle changes after discharge. What is the nurse's most appropriate response? A) Educate the patient about the link between alcohol use and pancreatitis. B) Ensure that the patient knows the importance of attending follow-up appointments. C) Refer the patient to social work or spiritual care. D) Encourage the patient to connect with a community-based support group.

D) Encourage the patient to connect with a community-based support group. Feedback: After the acute attack has subsided, some patients may be inclined to return to their previous drinking habits. The nurse provides specific information about resources and support groups that may be of assistance in avoiding alcohol in the future. Referral to Alcoholics Anonymous as appropriate or other support groups is essential. The patient already has an understanding of the effects of alcohol, and follow-up appointments will not necessarily result in lifestyle changes. Social work and spiritual care may or may not be beneficial.

13. A home health nurse is caring for a patient discharged home after pancreatic surgery. The nurse documents the nursing diagnosis Risk for Imbalanced Nutrition: Less than Body Requirements on the care plan based on the potential complications that may occur after surgery. What are the most likely complications for the patient who has had pancreatic surgery? A) Proteinuria and hyperkalemia B) Hemorrhage and hypercalcemia C) Weight loss and hypoglycemia D) Malabsorption and hyperglycemia

D) Malabsorption and hyperglycemia Feedback: The nurse arrives at this diagnosis based on the complications of malabsorption and hyperglycemia. These complications often lead to the need for dietary modifications. Pancreatic enzyme replacement, a low-fat diet, and vitamin supplementation often are also required to meet the patient's nutritional needs and restrictions. Electrolyte imbalances often accompany pancreatic disorders and surgery, but the electrolyte levels are more often deficient than excessive. Hemorrhage is a complication related to surgery, but not specific to the nutritionally based nursing diagnosis. Weight loss is a common complication, but hypoglycemia is less likely.

2. A 55-year-old man has been newly diagnosed with acute pancreatitis and admitted to the acute medical unit. How should the nurse most likely explain the pathophysiology of this patient's health problem? A) "Toxins have accumulated and inflamed your pancreas." B) "Bacteria likely migrated from your intestines and became lodged in your pancreas." C) "A virus that was likely already present in your body has begun to attack your pancreatic cells." D) "The enzymes that your pancreas produces have damaged the pancreas itself."

D) "The enzymes that your pancreas produces have damaged the pancreas itself." Feedback: Although the mechanisms causing pancreatitis are unknown, pancreatitis is commonly described as the autodigestion of the pancreas. Less commonly, toxic substances and microorganisms are implicated as the cause of pancreatitis.

This type of pancreatitis effects the majority of patients. Characterized by a lack of pancreatic or peripancreatic parenchymal necrosis with diffuse enlargement of the gland due to inflammatory edema.

Interstitial edematous pancreatitis

Mild and severe pancreatitis also known as:

Interstitial edematous pancreatitis and necrotizing pancreatitis.

Close monitoring of major organ function such as the __________ and ___________ is essential, and aggressive treatment is necessary to reduce mortality from acute pancreatitis in the older adult population.

Lungs, kidneys

A nurse is planning care for a client with acute pancreatitis. Which client outcome does the nurse assign as the highest priority?

Maintaining normal respiratory function Airway and breathing are always the priority assessment. Acute pancreatitis produces retroperitoneal edema, elevation of the diaphragm, pleural effusion, and inadequate lung ventilation. Intra-abdominal infection and labored breathing increase the body's metabolic demands, which further decreases pulmonary reserve and can lead to respiratory failure. Maintenance of adequate respiratory function is the priority goal. The other outcomes would also be appropriate for the patient.

What are the two main causes, in Western society, of chronic pancreatitis?

Malnutrition and alcohol consumption

Two main types of acute pancreatitis are:

Mild and severe

Chronic pancreatitis usually presents itself between the ages of ____-_____ years. Frequently at this age, patients already report a long history of alcohol abuse.

40-60 years

19. A nurse is assisting with serving dinner trays on the unit. Upon receiving the dinner tray for a patient admitted with acute gallbladder inflammation, the nurse will question which of the following foods on the tray? A) Fried chicken B) Mashed potatoes C) Dinner roll D) Tapioca pudding

A) Fried chicken Feedback: The diet immediately after an episode of acute cholecystitis is initially limited to low-fat liquids. Cooked fruits, rice or tapioca, lean meats, mashed potatoes, bread, and coffee or tea may be added as tolerated. The patient should avoid fried foods such as fried chicken, as fatty foods may bring on an episode of cholecystitis.

Describes acute gallbladder inflammation in the absence of obstruction by gallstones.

Acalculous cholecystitis

Occurs after major surgical procedures, orthopedic procedures, severe trauma, or burns. Other factors associated with this type include torsion, cystic duct obstruction, primary bacterial infections of the gallbladder, and multiple blood transfusions.

Acalculous cholecystitis

Can be a medical emergency associated with a high risk of life-threatening complications and mortality. whereas chronic pancreatitis often goes undetected

Acute pancreatitis

Ranges from a mild, self-limited disorder to a severe, rapidly fatal disease that does not respond to any treatment.

Acute pancreatitis

This type of pancreatitis affects people of all ages, but the mortality rate associated with it increases with age. In addition, the pattern of complications changes with age.

Acute pancreatitis

Approximately 200,000 cases of acute pancreatitis occur in the U.S. each year, of which 80% are the result of cholelithiasis or sustained ______________ abuse.

Alcohol

The incidence of pancreatitis is 50x higher in people with ______________ than those who do not abuse ___________. Smoking is another factor in the development of chronic pancreatitis.

Alcoholism, alcohol

18. A patient with gallstones has been prescribed ursodeoxycholic acid (UDCA). The nurse understands that additional teaching is needed regarding this medication when the patient states: A) "It is important that I see my physician for scheduled follow-up appointments while taking this medication." B) "I will take this medication for 2 weeks and then gradually stop taking it." C) "If I lose weight, the dose of the medication may need to be changed." D) "This medication will help dissolve small gallstones made of cholesterol."

B) "I will take this medication for 2 weeks and then gradually stop taking it." Feedback: Ursodeoxycholic acid (UDCA) has been used to dissolve small, radiolucent gallstones composed primarily of cholesterol. This drug can reduce the size of existing stones, dissolve small stones, and prevent new stones from forming. Six to 12 months of therapy is required in many patients to dissolve stones, and monitoring of the patient is required during this time. The effective dose of medication depends on body weight.

A client who had developed jaundice 2 months earlier is brought to the ED after attending a party and developing excruciating pain that radiated over the abdomen and into the back. Upon assessment, which additional symptom would the nurse expect this client to have?

Bile-stained vomiting Nausea and vomiting are common in acute pancreatitis. The emesis is usually gastric in origin but may also be bile stained. Fever, jaundice, mental confusion, and agitation may also occur.

5. A nurse who provides care in a walk-in clinic assesses a wide range of individuals. The nurse should identify which of the following patients as having the highest risk for chronic pancreatitis? A) A 45-year-old obese woman with a high-fat diet B) An 18-year-old man who is a weekend binge drinker C) A 39-year-old man with chronic alcoholism D) A 51-year-old woman who smokes one-and-a-half packs of cigarettes per day

C) A 39-year-old man with chronic alcoholism Feedback: Excessive and prolonged consumption of alcohol accounts for approximately 70% to 80% of all cases of chronic pancreatitis.

26. A student nurse is caring for a patient who has a diagnosis of acute pancreatitis and who is receiving parenteral nutrition. The student should prioritize which of the following assessments? A) Fluid output B) Oral intake C) Blood glucose levels D) BUN and creatinine levels

C) Blood glucose levels Feedback: In addition to administering enteral or parenteral nutrition, the nurse monitors serum glucose levels every 4 to 6 hours. Output should be monitored but in most cases it is not more important than serum glucose levels. A patient on parenteral nutrition would have no oral intake to monitor. Blood sugar levels are more likely to be unstable than indicators of renal function.

A gallbladder stone obstructs bile outflow in this type:

Calculous cholecystitis

Which foods should be avoided following acute gallbladder inflammation?

Cheese The client should avoid eggs, cream, pork, fried foods, cheese, rich dressings, gas-forming vegetables, and alcohol. It is important to remind the client that fatty foods may induce an episode of cholecystitis. Cooked fruits, rice or tapioca, lean meats, mashed potatoes, non-gas-forming vegetables, bread, coffee, or tea may be consumed as tolerated.

Inflammation of the gallbladder which can be acute or chronic. Causes pain, tenderness, and rigidity of the upper right abdomen that may radiate to the midsternal area or right shoulder and is associated with nausea, vomiting, and the usual signs of an acute inflammation.

Cholecystitis

Calculi, or gallstones, usually form in the gallbladder from the solid constituents of bile; they vary greatly in size, shape, and composition. They are uncommon in children and young adults but become more prevalent with increasing age. The incidence is also greater with those with diabetes and more in women.

Cholelithiasis

By the time symptoms occur in _____________ pancreatitis, approximately 90% of normal acinar cell function exocrine function has been lost. Late detection is not usually attributable to the vagueness of symptoms.

Chronic

An inflammatory disorder characterized by progressive destruction of the pancreas. As cells are replaced by fibrous tissue with repeated attacks of pancreatitis, pressure within the pancreas increases. The result is obstruction of the pancreatic and common bile ducts and the duodenum. There is also atrophy of the epithelium of the ducts, inflammation, and destruction of the secreting cells of the pancreas.

Chronic pancreatitis

Often goes undetected because classic clinical and diagnostic findings are not always present in the early stages of the disease.

Chronic pancreatitis

15. A patient returns to the floor after a laparoscopic cholecystectomy. The nurse should assess the patient for signs and symptoms of what serious potential complication of this surgery? A) Diabetic coma B) Decubitus ulcer C) Wound evisceration D) Bile duct injury

D) Bile duct injury Feedback: The most serious complication after laparoscopic cholecystectomy is a bile duct injury. Patients do not face a risk of diabetic coma. A decubitus ulcer is unlikely because immobility is not expected. Evisceration is highly unlikely, due to the laparoscopic approach.

33. A patient has been diagnosed with pancreatic cancer and has been admitted for care. Following initial treatment, the nurse should be aware that the patient is most likely to require which of the following? A) Inpatient rehabilitation B) Rehabilitation in the home setting C) Intensive physical therapy D) Hospice care

D) Hospice care Feedback: Pancreatic carcinoma has only a 5% survival rate at 5 years regardless of the stage of disease at diagnosis or treatment. As a result, there is a higher likelihood that the patient will require hospice care than physical therapy and rehabilitation.

20. A nurse is assessing an elderly patient with gallstones. The nurse is aware that the patient may not exhibit typical symptoms, and that particular symptoms that may be exhibited in the elderly patient may include what? A) Fever and pain B) Chills and jaundice C) Nausea and vomiting D) Signs and symptoms of septic shock

D) Signs and symptoms of septic shock Feedback: The elderly patient may not exhibit the typical symptoms of fever, pain, chills jaundice, and nausea and vomiting. Symptoms of biliary tract disease in the elderly may be accompanied or preceded by those of septic shock, which include oliguria, hypotension, change in mental status, tachycardia, and tachypnea.

A 70-year-old client is admitted with acute pancreatitis. The nurse understands that the mortality rate associated with acute pancreatitis increases with advanced age and attributes this to which gerontologic consideration associated with the pancreas?

Decreases in the physiologic function of major organs Acute pancreatitis affects people of all ages, but the mortality rate associated with acute pancreatitis increases with advancing age. The pattern of complications changes with age. Younger clients tend to develop local complications; the incidence of multiple organ failure increases with age, possibly as a result of progressive decreases in physiologic function of major organs with increasing age.

Which dietary modification is used for a client diagnosed with acute pancreatitis?

Elimination of coffee A high-carbohydrate, low-fat, and low-protein diet should be implemented. Alcohol, caffeine, and spicy foods should be avoided.

What should be done to a patient with electrolyte imbalance with acute pancreatitis?

Fluids administered via IV possibly accompanied by infusion of blood or blood products to maintain the blood volume and to prevent hypovolemic shock. Emergency meds must also be available b/c of risk of circulatory collapse and shock.

Which condition in a client with pancreatitis makes it necessary for the nurse to check fluid intake and output, check hourly urine output, and monitor electrolyte levels?

Frequent vomiting, leading to loss of fluid volume Fluid and electrolyte disturbances are common complications because of nausea, vomiting, movement of fluid from the vascular compartment to the peritoneal cavity, diaphoresis, fever, and the use of gastric suction. The nurse assesses the client's fluid and electrolyte status by noting skin turgor and moistness of mucous membranes. The nurse weighs the client daily and carefully measures fluid intake and output, including urine output, nasogastric secretions, and diarrhea.

A client comes to the ED with severe abdominal pain, nausea, and vomiting. The physician plans to rule out acute pancreatitis. The nurse would expect the diagnosis to be confirmed by an elevated result on which laboratory test?

Serum amylase Serum amylase and lipase concentrations are used to make the diagnosis of acute pancreatitis. Serum amylase and lipase concentrations are elevated within 24 hours of the onset of symptoms. Serum amylase usually returns to normal within 48 to 72 hours, but the serum lipase concentration may remain elevated for a longer period, often days longer than amylase. Urinary amylase concentrations also become elevated and remain elevated longer than serum amylase concentrations.

A nursing instructor is explaining the pathophysiology and clinical manifestations of pancreatitis to a group of nursing students. The instructor evaluates the teaching as effective when a student correctly identifies which symptom as that most commonly reported by clients with pancreatitis?

Severe, radiating abdominal pain Severe abdominal pain is the major symptom of pancreatitis that causes the client to seek medical care. The pain occurs in the midepigastrium. Abdominal pain and tenderness and back pain result from irritation and edema of the inflamed pancreas. Pain is frequently acute in onset, occurring 24 to 48 hours after a very heavy meal or alcohol ingestion; it may be diffuse and difficult to localize.

The physician has written the following orders for a new client admitted with pancreatitis: bed rest, nothing by mouth (NPO), and administration of total parenteral nutrition (TPN) . Which does the nurse attribute as the reason for NPO status?

To avoid inflammation of the pancreas

1. Which is the most common report by clients with pancreatitis?

a. severe, radiating abdominal pain Explanation: Clients with pancreatitis most commonly report severe mid- to upper-abdominal pain, radiating to both sides and straight to the back. The client may describe the stools as being frothy and foul smelling, not black or tarry. The client's urine may be dark. The client will not experience increased or painful urination, increased appetite, or weight gain.

Total parental nutrition (TPN) should be used cautiously in clients with pancreatitis because they

cannot tolerate a high glucose concentration. Total parenteral nutrition (TPN) is used carefully in clients with pancreatitis because some clients cannot tolerate a high glucose concentration, even with insulin coverage. Intake of coffee increases the risk for gallbladder contraction, whereas high protein intake increases risk for hepatic encephalopathy in clients with cirrhosis. Clients with pancreatitis should not be given high-fat foods because they are difficult to digest.

14. A patient has had a laparoscopic cholecystectomy. The patient is now complaining of right shoulder pain. What should the nurse suggest to relieve the pain? A) Aspirin every 4 to 6 hours as ordered B) Application of heat 15 to 20 minutes each hour C) Application of an ice pack for no more than 15 minutes D) Application of liniment rub to affected area

B) Application of heat 15 to 20 minutes each hour Feedback: If pain occurs in the right shoulder or scapular area (from migration of the CO2 used to insufflate the abdominal cavity during the procedure), the nurse may recommend use of a heating pad for 15 to 20 minutes hourly, walking, and sitting up when in bed. Aspirin would constitute a risk for bleeding.

31. A patient has been diagnosed with acute pancreatitis. The nurse is addressing the diagnosis of Acute Pain Related to Pancreatitis. What pharmacologic intervention is most likely to be ordered for this patient? A) Oral oxycodone B) IV hydromorphone (Dilaudid) C) IM meperidine (Demerol) D) Oral naproxen (Aleve)

B) IV hydromorphone (Dilaudid) Feedback: The pain of acute pancreatitis is often very severe and pain relief may require parenteral opioids such as morphine, fentanyl (Sublimaze), or hydromorphone (Dilaudid). There is no clinical evidence to support the use of meperidine for pain relief in pancreatitis. Opioids are preferred over NSAIDs.

12. A nurse is preparing a plan of care for a patient with pancreatic cysts that have necessitated drainage through the abdominal wall. What nursing diagnosis should the nurse prioritize? A) Disturbed Body Image B) Impaired Skin Integrity C) Nausea D) Risk for Deficient Fluid Volume

B) Impaired Skin Integrity Feedback: While each of the diagnoses may be applicable to a patient with pancreatic drainage, the priority nursing diagnosis is Impaired Skin Integrity. The drainage is often perfuse and destructive to tissue because of the enzyme contents. Nursing measures must focus on steps to protect the skin near the drainage site from excoriation. The application of ointments or the use of a suction apparatus protects the skin from excoriation.

30. A patient is receiving care in the intensive care unit for acute pancreatitis. The nurse is aware that pancreatic necrosis is a major cause of morbidity and mortality in patients with acute pancreatitis. Consequently, the nurse should assess for what signs or symptoms of this complication? A) Sudden increase in random blood glucose readings B) Increased abdominal girth accompanied by decreased level of consciousness C) Fever, increased heart rate and decreased blood pressure D) Abdominal pain unresponsive to analgesics

C) Fever, increased heart rate and decreased blood pressure Feedback: Pancreatic necrosis is a major cause of morbidity and mortality in patients with acute pancreatitis because of resulting hemorrhage, septic shock, and multiple organ dysfunction syndrome (MODS). Signs of shock would include hypotension, tachycardia and fever. Each of the other listed changes in status warrants intervention, but none is clearly suggestive of an onset of pancreatic necrosis.

39. A nurse is providing discharge education to a patient who has undergone a laparoscopic cholecystectomy. During the immediate recovery period, the nurse should recommend what foods? A) High-fiber foods B) Low-purine, nutrient-dense foods C) Low-fat foods high in proteins and carbohydrates D) Foods that are low-residue and low in fat

C) Low-fat foods high in proteins and carbohydrates Feedback: The nurse encourages the patient to eat a diet that is low in fats and high in carbohydrates and proteins immediately after surgery. There is no specific need to increase fiber or avoid purines. A low-residue diet is not indicated.

34. A patient is admitted to the ICU with acute pancreatitis. The patient's family asks what causes acute pancreatitis. The critical care nurse knows that a majority of patients with acute pancreatitis have what? A) Type 1 diabetes B) An impaired immune system C) Undiagnosed chronic pancreatitis D) An amylase deficiency

C) Undiagnosed chronic pancreatitis Feedback: Eighty percent of patients with acute pancreatitis have biliary tract disease or a history of long-term alcohol abuse. These patients usually have had undiagnosed chronic pancreatitis before their first episode of acute pancreatitis. Diabetes, an impaired immune function, and amylase deficiency are not specific precursors to acute pancreatitis.

17. A patient is being treated on the acute medical unit for acute pancreatitis. The nurse has identified a diagnosis of Ineffective Breathing Pattern Related to Pain. What intervention should the nurse perform in order to best address this diagnosis? A) Position the patient supine to facilitate diaphragm movement. B) Administer corticosteroids by nebulizer as ordered. C) Perform oral suctioning as needed to remove secretions. D) Maintain the patient in a semi-Fowler's position whenever possible.

D) Maintain the patient in a semi-Fowler's position whenever possible. Feedback: The nurse maintains the patient in a semi-Fowler's position to decrease pressure on the diaphragm by a distended abdomen and to increase respiratory expansion. A supine position will result in increased pressure on the diaphragm and potentially decreased respiratory expansion. Steroids and oral suctioning are not indicated.

1. A nurse is assessing a patient who has been diagnosed with cholecystitis, and is experiencing localized abdominal pain. When assessing the characteristics of the patient's pain, the nurse should anticipate that it may radiate to what region? A) Left upper chest B) Inguinal region C) Neck or jaw D) Right shoulder

D) Right shoulder Feedback: The patient may have biliary colic with excruciating upper right abdominal pain that radiates to the back or right shoulder. Pain from cholecystitis does not typically radiate to the left upper chest, inguinal area, neck, or jaw.

**A client with acute pancreatitis has been started on total parenteral nutrition (TPN). Which action should the nurse perform after administration of the TPN?

Measure blood glucose concentration every 4 to 6 hours

The nurse identifies a potential collaborative problem of electrolyte imbalance for a client with severe acute pancreatitis. Which assessment finding alerts the nurse to an electrolyte imbalance associated with acute pancreatitis?

Muscle twitching and finger numbness Muscle twitching and finger numbness indicate hypocalcemia, a potential complication of acute pancreatitis. Calcium may be prescribed to prevent or treat tetany, which may result from calcium losses into retroperitoneal (peripancreatic) exudate. The other data indicate other complications of acute pancreatitis but are not indicators of electrolyte imbalance.

In this type of pancreatitis, there is tissue necrosis in either the pancreatic parenchyma or in the tissue surrounding the gland. This type can be sterile or infected; if the parenchyma is involved this is a marker for more severe disease.

Necrotizing pancreatitis

Commonly described as autodigestion of the pancreas

Pancreatitis

A nurse is teaching a client about the cause of acute pancreatitis. The nurse evaluates the teaching as effective when the client correctly identifies which condition as a cause of acute pancreatitis?

Self-digestion of the pancreas by its own proteolytic enzymes Self-digestion of the pancreas by its own proteolytic enzymes, principally trypsin, causes acute pancreatitis. Of clients with acute pancreatitis, 80% had undiagnosed chronic pancreatitis. Gallstones enter the common bile duct and lodge at the ampulla of Vater, obstructing the flow of pancreatic juice or causing a reflux of bile from the common bile duct into the pancreatic duct, thus activating the powerful enzymes within the pancreas. Normally, these remain in an inactive form until the pancreatic secretions reach the lumen of the duodenum. Activation of the enzymes can lead to vasodilation, increased vascular permeability, necrosis, erosion, and hemorrhage.

Fluid and electrolyte disturbances are common complications of acute pancreatitis because of which of the following? SATA A) Nausea B) Lack of nutrition C) Vomiting D) Movement of fluid from vascular compartment to peritoneal cavity E) Diaphoresis F) Fever G) Use of gastric suction

A) Nausea C) Vomiting D) Movement of fluid from vascular compartment to peritoneal cavity E) Diaphoresis F) Fever G) Use of gastric suction

In addition to carefully monitoring vital signs and other signs/symptoms the nurse is responsible for administering what? SATA A) Prescribed fluids B) Medications C) Blood products D) Assisting with supportive management-ex. use of ventilator E) Preventing additional complications F) Providing physical and psychological care G) Providing the patient with a follow up appt. with doctor

A) Prescribed fluids B) Medications C) Blood products D) Assisting with supportive management-ex. use of ventilator E) Preventing additional complications F) Providing physical and psychological care

29. The family of a patient in the ICU diagnosed with acute pancreatitis asks the nurse why the patient has been moved to an air bed. What would be the nurse's best response? A) "Air beds allow the care team to reposition her more easily while she's on bed rest." B) "Air beds are far more comfortable than regular beds and she'll likely have to be on bed rest a long time." C) "The bed automatically moves, so she's less likely to develop pressure sores while she's in bed." D) "The bed automatically moves, so she is likely to have less pain."

C) "The bed automatically moves, so she's less likely to develop pressure sores while she's in bed." Feedback: It is important to turn the patient every 2 hours; use of specialty beds may be indicated to prevent skin breakdown. The rationale for a specialty bed is not related to repositioning, comfort, or ease of movement.

8. A patient who had surgery for gallbladder disease has just returned to the postsurgical unit from postanesthetic recovery. The nurse caring for this patient knows to immediately report what assessment finding to the physician? A) Decreased breath sounds B) Drainage of bile-colored fluid onto the abdominal dressing C) Rigidity of the abdomen D) Acute pain with movement

C) Rigidity of the abdomen Feedback: The location of the subcostal incision will likely cause the patient to take shallow breaths to prevent pain, which may result in decreased breath sounds. The nurse should remind patients to take deep breaths and cough to expand the lungs fully and prevent atelectasis. Acute pain is an expected assessment finding following surgery; analgesics should be administered for pain relief. Abdominal splinting or application of an abdominal binder may assist in reducing the pain. Bile may continue to drain from the drainage tract after surgery, which will require frequent changes of the abdominal dressing. Increased abdominal tenderness and rigidity should be reported immediately to the physician, as it may indicate bleeding from an inadvertent puncture or nicking of a major blood vessel during the surgical procedure.

Inflammation of the pancreas is called

Pancreatitis