med surg prepU ch 44 Assessment and Management of Patients with Biliary Disorders

The patient admitted with acute pancreatitis has passed the acute stage and is now able to tolerate solid foods. What type of diet will increase caloric intake without stimulating pancreatic enzymes beyond the ability of the pancreas to respond?

High-carbohydrate, low-protein, low-fat diet

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

A client with gallstones is diagnosed with acute pancreatitis and is requesting information about the physiology of the gallbladder. Which information will the nurse include about the function of this organ?

Releases bile in response to cholecystokinin

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

The nursing student has just reviewed material in the course textbook regarding pancreatitis. The student knows that a major symptom of pancreatitis that causes the client to seek medical care is:

severe abdominal pain

The nurse is caring for a client experiencing pain related to chronic pancreatitis. When developing a care plan for alternative strategies to opoid usage, which approaches will the nurse include? Select all that apply.

Vitamin E, Amytriptalyne, ibuprofen. In chronic pancreatitis, management of abdominal pain and discomfort is similar to that of acute pancreatitis; however, the focus is usually on the use of nonopioid methods to manage pain. Adjunct means of pain modulation include the use of antioxidants such as Vitamin E, antidepressants such as amitriptyline, avoiding alcohol, smoking cessation, and the use of nonopioid analgesics like ibuprofen.

The nurse is assessing a client admited with suspected pancreatitis. Which question will the nurse prioritize when assessing this client?

"How much alcohol do you consume in a day?" Explanation: Chronic pancreatitis is an inflammatory disorder characterized by progressive destruction of the pancreas. Alcohol consumption in Western societies is the major cause of chronic pancreatitis. Excessive and prolonged consumption of alcohol accounts for approximately 70% to 80% of all cases of chronic pancreatitis. The incidence of pancreatitis is 50 times greater in people with alcoholism than in those who do not abuse alcohol.

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?

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?

A nurse cares for a client with interstitial pancreatitis. What client teaching will the nurse include when planning care for the client?

"Inflammation is confined to only the pancreas."

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

yellow sclera

The nurse instructs a client on care at home after a laparoscopic cholecystectomy. Which client statement indicates that teaching has been effective?

"I should wash the site with mild soap and water." Explanation: After a laparoscopic cholecystectomy, the client should be instructed about pain management, activity and exercise, wound care, nutrition, and follow-up care. The client should be directed to wash the puncture site with mild soap and water when caring for the wound. When resuming activity, the client should be instructed to drive after 3 or 4 days, take a shower or bath after 1 or 2 days, and begin light exercise such as walking immediately.

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

"Maintain a high-sodium, high-calorie diet."

A nurse cares for a client who is post op cholecystectomy due to the development of cholesterol stones. The client asks the nurse, "Why did I develop these stones?" What is the nurse's best response?

"The stones formed from a component in the bile and are caused by bile acid and fat abnormalities in the bloodstream."

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."

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."

A nurse should monitor blood glucose levels for a patient diagnosed with hyperinsulinism. What blood glucose level 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 insulin-like 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

The nurse knows that the serum amylase concentration returns to normal within which time frame?

48 hours Explanation: Serum amylase usually returns to normal within 48 to 72 hours.

Ursodeoxycholic acid (UDCA) has been used to dissolve small, radiolucent gallstones. Which duration of therapy is required to dissolve the stones?

6 to 12 months

This example of cholesterol gallstones (left side of picture) is the result of decreased bile acid synthesis and increased cholesterol synthesis in the liver, which in turn, form stones. Cholesterol stones account for what percentage of cases of gallbladder disease in the United States?

75% Explanation: Cholesterol stones account for approximately 75% of cases of gallbladder disease in the United States.

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

A nurse is teaching a client and the client's family about chronic pancreatitis. Which are the major causes of chronic pancreatitis?

Alcohol consumption and smoking Explanation: Alcohol consumption in Western societies is a major factor in the development of chronic pancreatitis, as is smoking. Because heavy drinkers usually smoke, it is difficult to separate the effects of the alcohol abuse and smoking. Malnutrition is a major cause of chronic pancreatitis worldwide, but alcohol consumption is more commonly the cause in Western societies.

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.

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

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.

The nurse is caring for a client with a biliary disorder who has an elevated amylase level. If this elevation correlates to dysfunction, which body process does the nurse recognize may be impaired?

Carbohydrate digestion Explanation: Amylase is a pancreatic enzyme involved in the breakdown and digestion of carbohydrates. Trypsin aids in the digestion of proteins. Lipase aids in the digestion of fats.

A patient is admitted to the hospital with a possible common bile duct obstruction. What clinical manifestations does the nurse understand are indicators of this problem? (Select all that apply.)

Clay-colored feces Pruritus Jaundice

A client has a tumor of the head of the pancreas. What clinical manifestations will the nurse assess? Select all that apply.

Clay-colored stools Dark urine Jaundice

The nurse is caring for a client recovering from acute pancreatitis. Which menu item should the nurse remove from the client's breakfast tray?

Coffee Explanation: Post-acute management of the client with acute pancreatitis includes the introduction of solid food. Oral feedings that are low in fat and protein are gradually initiated. Caffeine is eliminated from the diet and therefore coffee, which contains caffeine, should be removed from the client's breakfast tray. Even decaffeinated coffee has a small amount of caffeine but could serve as a compromise for chronic coffee drinkers.

A nurse cares for a client who is post op open cholecystectomy. Upon assessment, the nurse notes the client's abdomen feels firm to palpation. What is the nurse's priority action?

Contact the health care provider Explanation: A client who is post op from open abdominal surgery is at risk for internal bleeding, which may manifest as rigidity of the abdomen. The nurse's priority is to contact the health care provider. Additional interventions will be necessary but contacting the health care provider is priority.

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.

The nurse is caring for a client with suspected chronic pancreatitis. Which diagnostic test or imaging does the nurse recognize as the most useful in diagnosing this condition?

ERCP

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

Edema and inflammation

A nurse is caring for a client in the emergency department who is reporting severe abdominal pain. The client is diagnosed with acute pancreatitis. Which laboratory value indicates further investigation?

Elevated troponin

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

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

A nurse is providing preoperative teaching to a client undergoing a cholecystectomy. Which topic should the nurse include in her teaching plan?

Increase respiratory effectiveness.

A client is scheduled for a cholecystogram for later in the day. What is the nurse's understanding on the diagnostic use of this exam?

It visualizes the gallbladder and bile duct. Explanation: The cholecystogram is a diagnostic imaging test used to visualize the gallbladder and bile duct. The celiac axis arteriography visualizes the liver and pancreas. Ultrasonography shows the sizes of the abdominal organs and detects any masses. The endoscopic retrograde cholangiopancreatography (ERCP) visualizes the biliary structures and pancreas via endoscopy.

Which enzyme aids in the digestion of fats?

Lipase Explanation: -Lipase is a pancreatic enzyme that aids in the digestion of fats. -Amylase aids in the digestion of carbohydrates. -Secretin is responsible for stimulating secretion of pancreatic juice. -Trypsin aids in the digestion of protein.

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 nurse provides care for a client who is postoperative for surgical cholecystectomy. Which symptom(s) is indicative of biliary blockage and thus requires health care provider (HCP) notification? **Drag the assessment data that indicates biliary blockage to the box on the right.**

Nausea Right Upper Quadrant 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?

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?

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

Packed red blood cells

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 the diagnosis of acute pancreatitis?

Pain with abdominal distention and hypotension Explanation: Assessment findings associated with pancreatitis include pain with abdominal distention and hypotension. -fatty diarrhea and hypotension are usually present. -the client typically experiences tachycardia

Which condition is the major cause of morbidity and mortality in clients with acute pancreatitis?

Pancreatic necrosis Explanation: Pancreatic necrosis is a major cause of morbidity and mortality in clients with acute pancreatitis. Shock and multiple organ failure may occur with acute pancreatitis.

The nurse is caring for a client with acute pancreatitis who is admitted to the intensive care unit to monitor for pulmonary complications. What is the nurse's understanding of the pathophysiology of pulmonary complications related to pancreatitis?

Pancreatitis can elevate the diaphragm and alter the breathing pattern.

The nurse cares for a client with cholecystitis with severe biliary colic symptoms. Which nursing intervention best promotes adequate respirations in a client with these symptoms?

Place the client in semi-Fowler's position.

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

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 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 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 board-like 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 board-like abdomen may develop and is generally an ominous sign, usually indicating peritonitis

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

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?

Use incentive spirometry every hour.

A client with chronic pancreatitis is treated for uncontrolled pain. Which complication does the nurse recognize is most common in the client with chronic pancreatitis?

Weight loss Explanation: Weight loss is most common in the client with chronic pancreatitis due to decreased dietary intake secondary to anorexia or fear that eating will precipitate another attack.

A nurse is caring for a client admitted with acute pancreatitis. Which nursing action is most appropriate for a client with this diagnosis?

Withholding all oral intake, as ordered, to decrease pancreatic secretions

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

cannot tolerate high-glucose concentration. Explanation: Total parental 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 intake of high protein increases risk for hepatic encephalopathy in clients with cirrhosis. Patients with pancreatitis should not be given high-fat foods because they are difficult to digest.

A preoperative client scheduled to have an open cholecystectomy says to the nurse, "The doctor said that after surgery, I will have a tube in my nose that goes into my stomach. Why do I need that?" What most common reason for a client having a nasogastric tube in place after abdominal surgery should the nurse include in a response?

decompression

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

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

pancreatitis

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

A patient is suspected to have pancreatic carcinoma and is having diagnostic testing to determine insulin deficiency. What would the nurse determine is an indicator for insulin deficiency in this patient? (Select all that apply).

-An abnormal glucose tolerance -Glucosuria -Hyperglycemia

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.

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

A client is admitted to the health care center with severe abdominal pain rated 10 on a 1-to-10 scale, tachycardia, hypertension, and muscle spasms. The nurse immediately administers morphine sulfate 4 mg slow intravenous pyelogram (IVP), as ordered. The nurse plans for which goal after administration of this mediation?

To increase the client's pain threshold

A patient is admitted to the hospital with possible cholelithiasis. What diagnostic test of choice will the nurse prepare the patient for?

ultrasonography