Prep-U Chapter 50: Assessment and management of patients with biliary disorders

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.

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

cannot tolerate a high glucose concentration. Explanation: 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.

A nurse is preparing a client for surgery. During preoperative teaching, the client asks where is bile stored. The nurse knows that bile is stored in the:

Gallbladder Explanation: The gallbladder functions as a storage depot for bile

A patient is receiving pharmacologic therapy with ursodeoxycholic acid or chenodeoxy-cholic acid for treatment of small gallstones. The patient asks the nurse how long the therapy will take to dissolve the stones. What is the best answer the nurse can give?

6 to 12 months Explanation: Ursodeoxycholic acid (UDCA [Urso, Actigall]) and chenodeoxycholic acid (chenodiol or CDCA [Chenix]) have been used to dissolve small, radiolucent gallstones composed primarily of cholesterol (Karch, 2012). Six to 12 months of therapy is required in many patients to dissolve stones, and monitoring of the patient for recurrence of symptoms or the occurrence of side effects (e.g., GI symptoms, pruritus, headache) is required during this time.

Which nursing action is most appropriate for a client hospitalized with acute pancreatitis?

Withholding all oral intake, as ordered, to decrease pancreatic secretions Explanation: The nurse should withhold all oral intake to suppress pancreatic secretions, which may worsen pancreatitis. Typically, this client requires a nasogastric tube to decompress the stomach and GI tract. Although pancreatitis may cause considerable pain, it's treated with I.M. meperidine (Demerol), not morphine, which may worsen pain by inducing spasms of the pancreatic and biliary ducts. No clinical evidence supports the use of meperidine for pain relief in pancreatitis, and, in fact, accumulation of its metabolites can cause CNS irritability and possibly seizures. Pancreatitis places the client at risk for fluid volume deficit from fluid loss caused by increased capillary permeability. Therefore, this client needs fluid resuscitation, not fluid restriction. A client with pancreatitis is most comfortable lying on the side with knees flexed.

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 Explanation: 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.

A client diagnosed with acute pancreatitis is being transferred to another facility. The nurse caring for the client completes the transfer summary, which includes information about the client's drinking history and other assessment findings. Which assessment findings confirm his diagnosis?

Recent weight loss and temperature elevation Explanation: Assessment findings associated with pancreatitis include recent weight loss and temperature elevation. Inflammation of the pancreas causes a response that elevates temperature and leads to abdominal pain that typically occurs with eating. Nausea and vomiting may occur as a result of pancreatic tissue damage that's caused by the activation of pancreatic enzymes. The client may experience weight loss because of the lost desire to eat. Blood in stools and recent hypertension aren't associated with pancreatitis; fatty diarrhea and hypotension are usually present. Presence of easy bruising and bradycardia aren't found with pancreatitis; the client typically experiences tachycardia, not bradycardia. Adventitious breath sounds and hypertension aren't associated with pancreatitis.

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 Explanation: 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.

Because clients with pancreatitis cannot tolerate high-glucose concentrations, total parental nutrition (TPN) should be used cautiously with them. Which of the following interventions has shown great promise in the prognosis of clients with severe acute pancreatitis?

Providing intensive insulin therapy Explanation: Intensive insulin therapy (continuous infusion) in the critically ill client has undergone much study and has shown promise in terms of positive client outcomes when compared with intermittent insulin dosing. Glycemic control with normal or near normal blood glucose levels improves client outcomes. Total parental nutrition (TPN) is used carefully in clients with pancreatitis because some clients cannot tolerate a high-glucose concentration, even with insulin coverage. Clients with pancreatitis should not be given high-fat foods because they are difficult to digest. The current recommendation for pain management in this population is parenteral opioids. The nurse should maintain the client in a semi-Fowler's position to reduce pressure on the diaphragm.

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.

A nurse should monitor blood glucose levels for a patient diagnosed with hyperinsulinism. What blood value does the nurse recognize as inadequate to sustain normal brain function?

30 mg/dL Explanation: Hyperinsulinism is caused by overproduction of insulin by the pancreatic islets. Occasionally, tumors of nonpancreatic origin produce an insulinlike material that can cause severe hypoglycemia and may be responsible for seizures coinciding with blood glucose levels that are too low to sustain normal brain function (i.e., lower than 30 mg/dL [1.6 mmol/L]) (Goldman & Schafer, 2012; McPherson & Pincus, 2011).

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 Explanation: 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.

Which foods should be avoided following acute gallbladder inflammation?

Cheese Explanation: 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.

A patient is diagnosed with mild acute pancreatitis. What does the nurse understand is characteristic of this disorder?

Edema and inflammation Explanation: Mild acute pancreatitis is characterized by edema and inflammation confined to the pancreas. Minimal organ dysfunction is present, and return to normal function usually occurs within 6 months.

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.

A client is diagnosed with gallstones in the bile ducts. The nurse knows to review the results of blood work for a

Serum bilirubin level greater than 1.0 mg/dL Explanation: Jaundice occurs in a few clients with gallbladder disease, usually with obstruction of the common bile duct. If the flow of bile is impeded (eg, by gallstones in the bile ducts), bilirubin does not enter the intestine. As a result, blood levels of bilirubin increase.

Which is the most common report by clients with pancreatitis?

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.

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 Explanation: Pancreatic secretion is increased by food and fluid intake and may cause inflammation of the 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.

A client with carcinoma of the head of the pancreas is scheduled for surgery. Which of the following should a nurse administer to the client before surgery?

Vitamin K Explanation: Clients with carcinoma of the head of the pancreas typically require vitamin K before surgery to correct a prothrombin deficiency. Potassium would be given only if the client's serum potassium levels were low. Oral bile acids are not prescribed for a client with carcinoma of the head of the pancreas; they are given to dissolve gallstones. Vitamin B has no implications in the surgery.

A nurse is providing dietary instructions to a client with a history of pancreatitis. Which instruction is correct?

"Maintain a high-carbohydrate, low-fat diet." Explanation: A client with a history of pancreatitis should avoid foods and beverages that stimulate the pancreas, such as fatty foods, caffeine, and gas-forming foods; should avoid eating large meals; and should eat plenty of carbohydrates, which are easily metabolized. Therefore, the only correct instruction is to maintain a high-carbohydrate, low-fat diet. An increased sodium or fluid intake isn't necessary because chronic pancreatitis isn't associated with hyponatremia or fluid loss.

A client has a nasogastric (NG) tube for suction and is NPO after a pancreaticoduodenectomy. Which explanation made by the nurse is the major purpose of this treatment?

"The tube allows the gastrointestinal tract to rest." Explanation: Postoperative management of clients who have undergone a pancreatectomy or a pancreaticoduodenectomy is similar to the management of clients after extensive gastrointestinal or biliary surgery. An NG tube with suction and parenteral nutrition allow the gastrointestinal tract to rest while promoting adequate nutrition.

A client discharged after a laparoscopic cholecystectomy calls the surgeon's office reporting severe right shoulder pain 24 hours after surgery. Which statement is the correct information for the nurse to provide to this client?

"This pain is caused from the gas used to inflate your abdominal area during surgery. Sitting upright in a chair, walking, or using a heating pad may ease the discomfort." Explanation: If pain occurs in the right shoulder or scapular area (from migration of the carbon dioxide used to insufflate the abdominal cavity during the procedure), the nurse may recommend using a heating pad for 15 to 20 minutes hourly, sitting up in a bed or chair, or walking.

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.

A nursing instructor is lecturing to a class about chronic pancreatitis. Which of the following does the instructor list as major causes?

Alcohol consumption and smoking Explanation: Alcohol consumption in Western societies and malnutrition worldwide are the major causes of chronic pancreatitis. Smoking is another factor in the development of chronic pancreatitis. Because heavy drinkers usually smoke, it is difficult to separate the effects of the alcohol abuse and smoking. Obesity is a form of malnutrition. Acute pancreatitis does not usually lead to chronic pancreatitis unless complications develop.

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 client with calculi in the gallbladder is said to have

Cholelithiasis Explanation: Calculi, or gallstones, usually form in the gallbladder from the solid constituents of bile; they vary greatly in size, shape, and composition. Cholecystitis is acute inflammation of the gallbladder. Choledocholithiasis is a gallstone in the common bile duct. Choledochotomy is an incision into the common bile duct.

What is the most appropriate nursing diagnosis for the client with acute pancreatitis?

Deficient fluid volume Explanation: Clients with acute pancreatitis often experience deficient fluid volume, which can lead to hypovolemic shock. Vomiting, hemorrhage (in hemorrhagic pancreatitis), and plasma leaking into the peritoneal cavity may cause the volume deficit. Hypovolemic shock will cause a decrease in cardiac output. Gastrointestinal tissue perfusion will be ineffective if hypovolemic shock occurs, but this wouldn't be the primary nursing diagnosis.

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.

The nurse admits a woman who is 8 weeks postpartum. The client presents with reports of severe right upper quadrant pain that radiates to her back. She states she just finished eating Thanksgiving dinner earlier that evening. The nurse suspects gallbladder disease. Statistics show that incidence of gallbladder disease is greater for women who are which of the following? Select all that apply.

Multiparous Obese Explanation: Two to three times more women than men develop cholesterol stones and gallbladder disease; affected women are usually older than 40 years, multiparous, and obese.

Which of the following conditions is most likely to involve a nursing diagnosis of fluid volume deficit?

Pancreatitis Explanation: Hypotension is typical and reflects hypovolemia and shock caused by the loss of large amounts of protein-rich fluid into the tissues and peritoneal cavity. The other conditions are less likely to exhibit fluid volume deficit.

Which condition is most likely to have a nursing diagnosis of fluid volume deficit?

Pancreatitis Explanation: Hypovolemic shock from fluid shifts is a major factor in acute pancreatitis. Appendicitis, cholecystitis, and gastric ulcer are less likely to exhibit fluid volume deficit.

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 patient with acute pancreatitis puts the call bell on to tell the nurse about an increase in pain. The nurse observes the patient guarding; the abdomen is boardlike and no bowel sounds are detected. What is the major concern for this patient?

The patient has developed peritonitis. Explanation: Abdominal guarding is present. A rigid or boardlike abdomen may develop and is generally an ominous sign, usually indicating peritonitis (Privette et al., 2011).

Sixty to eighty percent of pancreatic tumors occur in the head of the pancreas. Tumors in this region obstruct the common bile duct. Which of the following clinical manifestations would indicate a common bile duct obstruction associated with a tumor in the head of the pancreas? Choose all that apply.

Clay-colored stools Dark urine Jaundice Pruritis Explanation: 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.

When caring for a client with acute pancreatitis, the nurse should use which comfort measure?

Positioning the client on the side with the knees flexed Explanation: The nurse should place the client with acute pancreatitis in a side-lying position with knees flexed; this position promotes comfort by decreasing pressure on the abdominal muscles. The nurse should administer an analgesic, as needed and ordered, before pain becomes severe, rather than once each shift. Because the client needs a quiet, restful environment during the acute disease stage, the nurse should discourage frequent visits from family and friends. Frequent oral feedings are contraindicated during the acute stage to allow the pancreas to rest.

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 very ill client with acute cholecystitis is scheduled for surgery. The surgeon plans to create an incision in the common bile duct to remove stones. The nurse correctly documents this surgery in the electronic medical record using which term?

Choledochostomy Explanation: This procedure is reserved for the client with acute cholecystitis who may be too ill to undergo a surgical procedure. It involves making an incision in the common duct, usually to remove stones (choledochostomy).

Which is a clinical manifestation of cholelithiasis?

Clay-colored stools Explanation: The client with gallstones has clay-colored stools and excruciating upper right quadrant 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.

A client is admitted to the healthcare facility suspected of having acute pancreatitis and undergoes laboratory testing. Which of the following would the nurse expect to find?

Elevated urine amylase levels Explanation: Elevated serum and urine amylase, lipase, and liver enzyme levels accompany significant pancreatitis. If the common bile duct is obstructed, the bilirubin level is above normal. Blood glucose levels and white blood cell counts can be elevated. Serum electrolyte levels (calcium, potassium, and magnesium) are low.

Which of the following would be most appropriate for a client who is experiencing biliary colic?

Ensure that the client rests. Explanation: During an attack of biliary colic, the nurse should ensure that the client rests. The nurse should not give the client a full meal; instead, the nurse should monitor the client's ability to digest a bland liquid diet. The nurse should also administer antispasmodics or analgesics as prescribed to relieve pain and discomfort.

Upon receiving the dinner tray for a client admitted with acute gallbladder inflammation, the nurse will question which of the following foods on the tray?

Hot roast beef sandwich with gravy Explanation: 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 client should avoid fried foods such as fried chicken, because fatty foods may bring on an episode of cholecystitis.

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 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 Explanation: 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.

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.

A client is admitted to the health care facility with abdominal pain, a low-grade fever, abdominal distention, and weight loss. The physician diagnoses acute pancreatitis. What is the primary goal of nursing care for this client?

Relieving abdominal pain Explanation: The predominant clinical feature of acute pancreatitis is abdominal pain, which usually reaches peak intensity several hours after onset of the illness. Therefore, relieving abdominal pain is the nurse's primary goal. Because acute pancreatitis causes nausea and vomiting, the nurse should try to prevent fluid volume deficit, not overload. The nurse can't help the client achieve adequate nutrition or understand the disease and its treatment until the client is comfortable and no longer in pain.

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.

The nurse should assess for an important early indicator of acute pancreatitis, which is a prolonged and elevated level of:

Serum lipase Explanation: In most cases, serum amylase and lipase levels are elevated within 24 hours of the onset of the symptoms. Serum amylase usually returns to normal within 48 to 72 hours, but serum lipase levels may remain elevated for a longer period, often days longer than amylase.