Chapter 50: Assessment and Management of Patients With Biliary Disorders

A client with suspected biliary obstruction due to gallstones reports changes to the color of his stools. Which stool color does the nurse recognize as common to biliary obstruction?

Gray Explanation: A gray-white stool color is common with a biliary obstruction because the stool is no longer colored with bile pigments.

One difference between cholesterol stones (left) and the stones on the right are that the ones on the right account for only 10% to 25% of cases of stones in the United States. What is the name of the stones on the right?

Pigment Explanation: There are two major types of gallstones: those composed predominantly of pigment and those composed primarily of cholesterol. Pigment stones probably form when unconjugated pigments in the bile precipitate to form stones; these stones account for 10% to 25% of cases in the United States. There are no gallstones with the names of pearl, patterned, or pixelated.

When the nurse is caring for a patient with acute pancreatitis, what intervention can be provided in order to prevent atelectasis and prevent pooling of respiratory secretions?

Frequent changes of positions Explanation: Frequent changes of position are necessary to prevent atelectasis and pooling of respiratory secretions.

A student nurse is preparing a plan of care for a client with chronic pancreatitis. What nursing diagnosis related to the care of a client with chronic pancreatitis is the priority?

Impaired nutrition: less than body requirements Explanation: While each diagnosis may be applicable to this client, the priority nursing diagnosis is impaired nutrition: less than body requirements. The physician, nurse, and dietitian emphasize to the client and family the importance of avoiding alcohol and foods that have produced abdominal pain and discomfort in the past. Oral food or fluid intake is not permitted during the acute phase.

A client with acute pancreatitis reports muscle cramping in the lower extremities. What pathophysiology concept represents the reason the client is reporting this?

Tetany related to hypocalcemia Explanation: A client with acute pancreatitis who reports muscle cramping or pain should be suspected of having hypocalcemia and tetany of the muscles. Hypocalcemia may occur in acute pancreatitis because, when auto digestion of the pancreas occurs, calcium binds to fatty acids and calcium is decreased in the blood. This is a potentially life-threatening complication of pancreatitis and needs to be immediately addressed.

A nurse is caring for a client with mild acute pancreatitis. Which health care provider prescriptions will the nurse question as it relates to evidence based practices in the treatment of acute pancreatitis? Select all that apply.

Full liquid diet as tolerated. Nasogastric tube to intermittent wall suction for removal of gastric secretions. Initiate parenteral feedings first and advance to enteral feedings as tolerated. Explanation: The nurse should question any order for clear liquid diet because oral intake should be held to inhibit pancreatic enzyme secretion. However, enteral feedings should be initiated as soon as possible, as the client tolerates them. The placement of a nasogastric tube to wall suction is recommended for the treatment of nausea, vomiting, or abdominal distention only; routine use of a nasogastric tube for removal of gastric secretions in order to limit pancreatic enzymes is not recommended. Enteral feedings should be tried first before parenteral feedings.

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 Explanation: 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 being treated for pancreatitis faces the risk of atelectasis. Which of the following interventions would be important to implement to minimize this risk?

Reposition the client every 2 hours. Explanation: Repositioning the client every 2 hours minimizes the risk of atelectasis in a client who is being treated for pancreatitis. The client should be instructed to cough every 2 hours to reduce atelectasis. Monitoring the pulse oximetry helps show changes in respiratory status and promote early intervention, but it would do little to minimize the risk of atelectasis. Withholding oral feedings limits the reflux of bile and duodenal contents into the pancreatic duct.

A client is evaluated for severe pain in the right upper abdominal quadrant, which is accompanied by nausea and vomiting. The physician diagnoses acute cholecystitis and cholelithiasis. For this client, which nursing diagnosis takes top priority?

Acute pain related to biliary spasms Explanation: The chief symptom of cholecystitis is abdominal pain or biliary colic. Typically, the pain is so severe that the client is restless and changes positions frequently to find relief. Therefore, the nursing diagnosis of Acute pain related to biliary spasms takes highest priority. Until the acute pain is relieved, the client can't learn about prevention, may continue to experience anxiety, and can't address nutritional concerns.

A client with a history of alcohol abuse comes to the emergency department and complains of abdominal pain. Laboratory studies help confirm a diagnosis of acute pancreatitis. The client's vital signs are stable, but the client's pain is worsening and radiating to his back. Which intervention takes priority for this client?

Administering morphine I.V. as ordered Explanation: The nurse should address the client's pain issues first by administering morphine I.V. as ordered. Placing the client in a Semi-Fowler's position, maintaining NPO status, and providing mouth care don't take priority over addressing the client's pain issues.

The nurse is planning care for a client following an incisional cholecystectomy for cholelithiasis. Which intervention is the highest nursing priority for this client?

Assisting the client to turn, cough, and deep breathe every 2 hours Explanation: Assessment should focus on the client's respiratory status. If a traditional surgical approach is planned, the high abdominal incision required during surgery may interfere with full respiratory excursion. The other nursing actions are also important, but are not as high a priority as ensuring adequate ventilation.

A nurse is reviewing the health care provider orders for a client admitted with acute pancreatitis. The health care provider has ordered intravenous calcium chloride infusions for the client. What does the nurse understand is the reason for this order?

Calcium binds to fatty acids when auto digestion of the pancreas occurs. Explanation: Hypocalcemia is a potential problem with acute pancreatitis because calcium binds to fatty acids when auto digestion of the pancreas occurs.

Several clinical manifestations are associated with a tumor of the head of the pancreas. Choose all that apply.

Clay-colored stools Dark urine Jaundice Explanation: Sixty to eighty percent of pancreatic tumors occur in the head of the pancreas. Tumors in this region obstruct the common bile duct. The obstructed flow of bile produces jaundice, clay-colored stools, and dark urine. Malabsorption of nutrients and fat-soluble vitamins may result if the tumor obstructs the entry of bile to the gastrointestinal tract. Abdominal discomfort or pain and pruritus may be noted, along with anorexia, weight loss, and malaise. If these signs and symptoms are present, cancer of the head of the pancreas is suspected.

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 Explanation: 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.

Increased appetite and thirst may indicate that a client with chronic pancreatitis has developed diabetes melitus. Which of the following explains the cause of this secondary diabetes? You Selected:

Dysfunction of the pancreatic islet cells Explanation: Diabetes mellitus resulting from dysfunction of the pancreatic islet cells is treated with diet, insulin, or oral antidiabetic agents. The hazard of severe hypoglycemia with alcohol consumption is stressed to the client and family. When secondary diabetes develops in a client with chronic pancreatitis, the client experiences increased appetite, thirst, and urination. A standard treatment with pancreatitis is to make the client NPO. The dysfunction is related to the pancreas, not the liver. Reference:

A critical care nurse is caring for a client with acute pancreatitis. One potentially severe complication involves the respiratory system. Which of the following would be an appropriate intervention to prevent complications associated with the respiratory system?

Maintain the client in a semi-Fowler's position. Explanation: The nurse maintains the client in the semi-Fowler's position to decrease pressure on the diaphragm by a distended abdomen and to increase respiratory expansion. Respiratory distress and hypoxia are common, and the client may develop diffuse pulmonary infiltrates, dyspnea, tachypnea, and abnormal blood gas values. The client who has undergone surgery may have multiple drains or an open surgical incision and is at risk for skin breakdown and infection. Oral food or fluid intake is not permitted; therefore, enteral or parenteral feedings may be prescribed.

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 Explanation: Enteral or parenteral nutrition may be prescribed. In addition to administering enteral or parenteral nutrition, the nurse monitors the serum glucose concentration every 4 to 6 hours.

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 Explanation: 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.

The nurse is admitting a patient to the intensive care unit with a diagnosis of acute pancreatitis. What does the nurse expect was the reason the patient came to the hospital? You Selected:

Severe abdominal pain Explanation: Severe abdominal pain is the major symptom of pancreatitis that causes the patient to seek medical care. Abdominal pain and tenderness and back pain result from irritation and edema of the inflamed pancreas.

The nurse is caring for a patient with acute pancreatitis. The patient has an order for an anticholinergic medication. The nurse explains that the patient will be receiving that medication for what reason?

To reduce gastric and pancreatic secretions Explanation: Anticholinergic medications reduce gastric and pancreatic secretion.

The digestion of carbohydrates is aided by

amylase. Explanation: Amylase is secreted by the exocrine pancreas. Lipase aids in the digestion of fats. Trypsin aids in the digestion of proteins. Secretin is the major stimulus for increased bicarbonate secretion from the pancreas.

A client with cholelithiasis has a gallstone lodged in the common bile duct. When assessing this client, the nurse expects to note:

yellow sclerae. Explanation: Yellow sclerae are an early sign of jaundice, which occurs when the common bile duct is obstructed. Urine normally is light amber. Circumoral pallor and black, tarry stools don't occur in common bile duct obstruction; they are signs of hypoxia and GI bleeding, respectively.