Gastrointestinal System (Liver Cancer, Gallbladder, Pancreatic Disorders)

Which statement made by the student nurse when caring for a patient who has had an open cholecystectomy requires correction?

"I will teach the patient to resume normal activities in 2 weeks." Rationale: A patient who had an open cholecystectomy has a subcostal incision and will need to be instructed to wait 6 weeks to resume normal activities.

What would be the best collaborative care intervention for a patient admitted for treatment of an acute episode of cholecystitis who reports dry skin and severe itching?

Administer cholestyramine Rationale: Cholestyramine is a cholesterol solvent that binds bile in the small intestine for fecal elimination. It prevents bile from being reabsorbed and irritating the skin.

Magnetic resonance imaging (MRI)/MRCP

Assists providers in diagnosing and staging tumors

Which intervention should the nurse include when planning care to improve the nutritional status of a patient with cirrhosis?

Give the patient smaller meals and snacks throughout the day. Rationale: Because of ascites in the abdomen and decreased appetite associated with cirrhosis, the nurse should provide the patient with smaller, more frequent meals throughout the day.

Which should the nurse include in the plan of care for a client undergoing external beam radiation therapy for pancreatic cancer?

Skin care Rationale: Radiation therapy can cause skin irritation at the radiated site. Therefore, the nurse should include meticulous skin care in the care plan.

A nurse is caring for a young man with a history of alcoholic cirrhosis. He presents to the clinic with pain in the upper right quadrant, weight loss, and fever. Which action by the nurse is most appropriate?

Talk to the health care provider about ordering an abdominal CT scan.

The nurse is preparing to administer a unit of fresh frozen plasma to a patient with cirrhosis admitted for a transjugular intrahepatic portosystemic shunt (TIPS) procedure. The patient's caregiver asks why the patient will be receiving fresh frozen plasma. What is the nurse's best response?

"Fresh frozen plasma provides the patient with the necessary clotting factors that the liver is not producing."

Which laboratory values will the nurse expect to be decreased in the patient with cirrhosis?

Albumin The patient with cirrhosis will present with a decreased serum albumin level as a result of malnutrition and increased oncotic pressure. Calcium The calcium level is decreased in a patient with cirrhosis as a result of malnutrition. Potassium The patient with cirrhosis will have a decreased potassium level as a result of hyperaldosteronism

Endoscopic retrograde cholangiopancreatography (ERCP)

Allows visualization of the pancreatic duct and biliary system

An elevation in which laboratory value can lead to increased confusion and lethargy in the patient with cirrhosis?

Ammonia

Which laboratory value must the nurse assess before administration of lactulose?

Ammonia level Lactulose is given to a patient with hepatic encephalopathy to reduce serum ammonia levels. Therefore the nurse will assess the patient's ammonia level before administration of this drug.

A 55-year-old obese African American woman has been admitted for a cholecystectomy to treat cholecystitis. The patient asks the nurse what factors might have predisposed her to cholecystitis. Which factors would the nurse mention?

Being female Being overweight Over the age of 40

The nurse is reviewing the admission history and physical examination findings for a patient with a history of cirrhosis who is being admitted for the third time in 6 months. Which laboratory finding would indicate the patient has not followed the plan of care previously discussed at discharge?

Blood alcohol level 160 mg/dL At discharge, the patient with cirrhosis would have been instructed to abstain from alcohol to prevent further hepatic damage. The blood alcohol level is twice the legal limit, which indicates the patient has not followed the plan of care.

Possible drugs include fluorouracil (5-FU) and gemcitabine (Gemzar), either alone or in combination with other drugs, such as:

Capecitabine Paclitaxel Erlotinib Irinotecan

The causes of pancreatic cancer are not completely understood, but risk factors include:

Chronic pancreatitis Diabetes mellitus Advanced age Cigarette smoking (most significant risk factor) Family history High-fat diet Exposure to chemicals Ethnicity (African-American more susceptible)

The nurse is caring for a patient with cirrhosis and an elevated prothrombin time/international normalized ratio (PT/INR). Which complication is this patient most at risk for developing?

Gastrointestinal hemorrhage Rationale: A patient with cirrhosis will have impaired clotting as a result of liver damage. The patient may also have esophageal and gastric varices, which can rupture easily with an elevated PT/INR and cause gastrointestinal hemorrhage.

The nurse is reviewing the diagnostic reports for a patient admitted with a palpable mass in the liver. Which finding in the medical record suggests metastatic liver cancer as opposed to primary liver cancer?

Masses noted in the brain, breast, and colon Rationale: Primary liver cancer tends to spread to the lungs and peritoneum. Masses noted in the brain, breast, and colon suggest metastasis to the liver from another primary site.

Pathophysiology of Pancreatic Cancer

Most cases of pancreatic cancer are adenocarcinomas that begin in the head of the pancreas. As the tumor grows, it obstructs the bile ducts and the patient develops jaundice. Tumors that start in the body or the tail tend to have no signs of growth until the disease has spread. The prognosis is poor and survival after diagnosis may be as short as 5-12 months.

Cirrhosis

Normal liver tissue is replaced with fibrotic scar tissue. *****Postnecrotic: Due to viral hepatitis, toxins, or medications. *****Laennec's: Due to chronic alcoholism. *****Biliary: Due to chronic biliary obstruction Signs & Symptoms: Jaundice, ascities, petechiae, spider angiomas, palmar erythema, pruritis (itching), confusion, fatigue, GI bleeding, asterixis, fetor hepaticus (fruit breath), peripheral edema. Labs: Increased ALT, AST, bilirubin, ammonia levels. Decreased serum protein, albumin, RBC, Hbg, Hct, platelets, potassium, calcium. Prescribed diet:high in calories, low in fat, and low in sodium. Fluid restrictions may be required if the patient is retaining excess fluid.

Symptoms of pancreatic cancer may include:

Pain Related to the location of the malignancy (upper abdomen or left hypochondrium) That is dull, aching, and radiates to the back. Often related to eating That is extreme and unrelenting if malignancy has extended to retroperitoneal and nerve plexuses Nausea Anorexia Progressive weight loss Jaundice Pruritus

A patient presents to the emergency department and reports frequent small light-colored stools and fever. On examination, the nurse notes jaundice of the skin and sclera and a white blood cell (WBC) count of 15,000 /μL. An ultrasound examination indicates the patient has a dilated common bile duct with gallstones. What is the priority nursing intervention for this patient?

Prepare the patient for an endoscopic retrograde cholangiopancreatography (ERCP) Rationale: The patient has symptoms of an obstruction in the common bile duct, so the nurse will prepare the patient for an ERCP, which allows the surgeon to visualize and remove the stone.

Pancreatic body and/or tail tumors Distal pancreatectomy

The head of the pancreas remains intact, so the patient will not need insulin replacement or pancreatic enzymes.

Hepatitis

Routes of Transmission *****Hep A: fecal/oral *****Hep B: blood/body fluids *****Hep C: blood/body fluids Risk Factors: IV drug use, body piercing, tattoos, unprotected sex, travel to underdeveloped countries, crowded living environments. Symptoms: Flu-like symtoms, fever, jaundice, dark-colored urine, clay colored stools. Labs: Increased ALT, AST bilirubin

A patient who is not a candidate for surgery is admitted to the hospital with acute cholecystitis and severe nausea and vomiting. Which collaborative care intervention will help maintain fluid and electrolyte balances?

Start an intravenous infusion of lactated Ringer's solution Rationale: Giving the patient intravenous fluids will help restore and maintain fluid and electrolyte balances affected by nausea and vomiting.

The nurse is assessing a patient for pain related to pancreatitis. Which statements about pain would the nurse anticipate from the patient?

The pain comes on suddenly." The pain of acute pancreatitis has sudden onset. "The pain gets worse when I eat." Acute pancreatitis causes pain that is intensified by eating due to the release of pancreatic enzymes in response to food. "The pain is severe, deep, and piercing." Patients state the pain of acute pancreatitis is severe, deep, and piercing. Pain happens because of the distention of the pancreas, peritoneal irritation, and biliary tract obstruction.

Total pancreatectomy

The pancreas is often not removed because of a patient's reliance on insulin treatment and pancreatic enzymes.

The family of a patient with recently diagnosed pancreatic cancer asks the nurse why a positron emission tomography (PET) scan is being done since the patient already has a cancer diagnosis. Which is the best response by the nurse?

"A PET scan will show tumor spread and will help the health care provider determine the stage of the cancer." Rationale: A PET scan is used to determine the stage at time of diagnosis and monitor progress and response to therapy.

Following teaching, the nurse is evaluating the patient's understanding of the need for both an endoscopic retrograde cholangiopancreatography (ERCP), plus endoscopic sphincterotomy, and a laparoscopic cholecystectomy. Which statement by the patient indicates the need for further teaching?

"A laparoscopic cholecystectomy visualizes the colon, and the ERCP removes the gallstones." Rationale: A laparoscopic cholecystectomy removes the gallbladder, while the ERCP visualizes the biliary ducts and can remove the gallstones lodged in the ducts. Since these procedures are reversed by the patient, this indicates the need for further teaching.

The nurse is assessing a patient admitted for evaluation of abdominal pain and suspected pancreatic cancer. The patient reports upper abdominal pain. Which question should the nurse ask the patient to obtain more information about the pain?

"Have you had any significant weight loss?" Pancreatic cancer causes weight loss as a lack of digestive enzymes results in poor absorption.

The nurse is teaching a community group of working adults about ways to reduce their risk for pancreatic cancer. Which statement by a participant indicates a need for further teaching?

"I should decrease the number of cigarettes I smoke per day." Rationale: The patient needs further teaching to understand that smoking is the biggest risk factor for developing pancreatic cancer. Smoking cessation, not reducing the amount one smokes, would lower a patient's risk for pancreatic cancer.

The nurse is completing patient education for a patient to be discharged after undergoing an open cholecystectomy. Which statement by the patient indicates effective teaching by the nurse?

"I should not be carrying the laundry baskets upstairs." Rationale: Heavy lifting should be avoided for 4 to 6 weeks after an open cholecystectomy.

A nurse is teaching a patient about self-management following a total pancreatectomy secondary to pancreatic cancer. Which statement by the patient indicates an understanding of the impact of self-management needs following surgery?

"I will need to give myself insulin injections for the rest of my life." Rationale: The pancreas is responsible for making insulin. Since the patient's pancreas is removed, the patient will need to receive insulin injections for life.

The nurse is providing discharge teaching to a male patient with cirrhosis about managing his care at home. Which statement made by the patient indicates a need for further teaching?

"I will weigh myself every other day." It is important for the patient to weigh himself every day to determine whether he has retained fluid. This statement indicates a need for further teaching.

A patient who has undergone laparoscopic cholecystectomy asks the nurse about getting up and taking a shower. Which response by the nurse would be appropriate?

"It is best to do a bedside bath because you want to keep the dressing dry" Rationale: The patient should not get the incisions wet for a few days after the procedure until the primary health care provider allows it. A bed bath is a solution for cleaning the patient without getting the incisions wet.

A nurse is conducting a group counseling session for patients with liver cancer. One of the participants begins to cry and is upset that his terminal cancer was not diagnosed earlier. Which statements by other members of the group should be corrected by the nurse?

"Maybe you should request a needle biopsy to confirm the diagnosis." Rationale: The nurse should explain that needle biopsy of liver tumors is not recommended due to the risk of the cancer spreading along the needle track.

A nurse is reviewing medications with a patient who is being discharged after having an esophageal variceal bleed. The patient questions why propranolol is being prescribed when blood pressure is low. What is the nurse's best response?

"Propranolol will help decrease the portal pressure to prevent further bleeding from existing varices."

The nurse is caring for a patient with diagnosed pancreatic cancer. The patient asks why chemotherapy and radiation are required, in addition to surgery. Which is the nurse's best response?

"Radiation alone has not been proven to be effective in pancreatic cancer treatment." Pancreatic cancer does not usually respond well to the use of radiation only. It does respond better with a rounded approach of surgery, chemotherapy, and radiation

A nurse is caring for a patient who is diagnosed with liver cancer. As part of the initial diagnostic testing, the provider orders a chest CT scan. The patient asks why this test is necessary. How should the nurse respond?

"The CT scan is used to determine if there is any metastasis." Rationale: Primary liver cancer frequently metastasizes to the lungs and the peritoneum.

The nursing instructor asks the student nurse caring for a patient who has undergone open cholecystectomy with placement of a T tube to explain the reason for placement of the T tube. Which statement by the student indicates accurate understanding?

"The T tube ensures patency of the bile duct and allows excess bile to drain until edema decreases." Rationale: The body's response to surgery is inflammation. The area around the bile duct will be inflamed after an open cholecystectomy. The T tube provides a means of draining the excess bile, since the gallbladder is no longer is available for storage.

The nurse is completing the preoperative checklist for a patient with primary liver cancer who is undergoing a partial hepatectomy. Which statement made by the patient indicates the patient understands the procedure?

"The surgeon is going to remove the cancerous tumors." Rationale: A partial hepatectomy involves removing a portion of the liver that has cancerous tumors. Therefore, this statement indicates the patient understands the procedure.

A patient with newly diagnosed pancreatic cancer is admitted to the medical floor with jaundice. The patient asks the nurse why he has yellowish skin when his father with pancreatic cancer never had it. Which is the nurse's best response?

"The yellowish skin color means the tumor is blocking the release of bile from the liver." Rationale: Jaundice occurs when a tumor on the head of the pancreas obstructs biliary ducts.

The nurse is teaching a patient being treated for cholecystitis about the anticholinergic medication that has just been prescribed. Which information provided by the nurse accurately describes the use of this medication for cholecystitis?

"This medication will decrease gastrointestinal (GI) secretions and reduce gallbladder spasms." Rationale: Anticholinergic drugs have a drying effect and will decrease GI secretions, as well as gallbladder spasms.

A patient admitted for evaluation of pancreatitis is scheduled for a chest x-ray. Which explanation provided by the nurse to the patient explains the need for a chest x-ray?

"We need to assess for pulmonary complications related to pancreatitis." RationaleL The pain of pancreatitis can prevent the patient from taking deep breaths and places them at risk for atelectasis and pneumonia. Pancreatitis also leads to pulmonary infiltrates. The chest x-ray will assess for pulmonary changes.

Nursing interventions encompass both symptomatic and supportive measures, including:

Administering medications Providing comfort measures Providing nutritional support, including frequent feedings and supplements Implementing steps to manage the effects of anorexia, or any nausea/vomiting Providing skin care for patients receiving radiation therapy

Abdominal ultrasound

Allows direct imaging of tumors or growths

Endoscopic ultrasound (EUS)

Allows imaging of the pancreas via endoscope; allows for fine-needle aspiration of the tumor for pathologic examination

Which priority assessments should the nurse make before a patient undergoes a transjugular intrahepatic portosystemic shunt (TIPS) procedure?

Ammonia level A TIPS procedure is contraindicated for patients with elevated ammonia levels. TIPS directs blood flow from the mesentery to the brain and can increase ammonia levels. Therefore the nurse should assess the ammonia level before the patient undergoes this procedure. Prothrombin time A TIPS procedure is an invasive procedure, which requires a needle to be inserted into the jugular vein. The nurse should assess prothrombin time before the patient undergoes this procedure.

The nurse is preparing to administer an injection to a patient being treated for obstructive choledocholithiasis. The patient has been having severe episodes of nausea and vomiting and has a temperature of 100.2° F and bleeding gums. Which actions taken by the nurse will reduce potential complications from the injection?

Apply gentle pressure to the injection site Choose a 23-gauge needle to administer the medication

The nurse is caring for a patient being treated for acute pancreatitis and notes that the patient's arms are jerking and that they are experiencing muscular twitching. The patient is also complaining of numbness and tingling in the fingers. Which should be the nurse's initial action?

Assess for Chvostek's sign or Trousseau's sign Rationale: When a patient experiences arm jerking, muscle twitching, numbness and tingling in the fingers, and facial twitching, the nurse would assess for Chvostek's sign or Trousseau's sign as these are considered signs of hypocalcemia, which is frequently found in acute pancreatitis

A nurse is planning hospice care for a patient with advanced pancreatic cancer. Which action is the most significant to include in the nursing care plan?

Assess the patient for depression and anxiety Rationale: The nurse should assess the patient's psychological status and coping mechanisms when planning hospice care. Depression and anxiety are common and require psychological support.

What should the nurse include in a focused assessment when caring for a patient admitted to the hospital with a diagnosis of cirrhosis?

Assess the lower extremities. Assess skin integrity and color. Measure abdominal circumference.

The nurse is caring for a patient with pancreatitis who just consulted with the dietician. Which menu selection indicates effective patient understanding of the prescribed diet?

A pancake with syrup and 2% milk When the patient with pancreatitis is allowed to eat, the prescribed diet will be high in carbohydrates. Pancakes with syrup and 2% milk are high in carbohydrates and are a good menu choice.

The nurse is caring for a patient receiving nonoperative treatment for cholelithiasis. The nurse enters the patient's room, and the family asks how the patient will be kept comfortable, since surgery is not an option. Which nursing interventions will address the family's concerns?

Administer opioid analgesics. Administration of opioid analgesics is a nonoperative treatment for cholelithiasis. Provide the patient with a low-fat diet. Decreasing the amount of fat in the diet can prevent pain related to cholelithiasis. This is a nonoperative treatment.

Pancreatitis

Autodigestion of the pancreas by pancreatic digestive enzymes that are prematurely activated before reaching the intestines. Risk Factors: Bile tract disease, alcohol abuse, GI surgery, trauma, medication toxicity. Signs/Symptoms: Severe LUQ or epigastric pain (radiating to the back or left shoulder)), May be aggravated by eating due to the release of pancreatic enzymes. Not relieved by vomiting. Described as severe, deep, piercing and continuous or steady Onset is sudden, often occurring while lying down Abdominal tenderness with muscle guarding is common n/v, Turner's sign (ecchymoses on flanks), Cullen's sign (blue/grey discoloration around umbilicus), jaundice, ascites, tetany. Labs: Increased amylase, lipase, WBC, bilirubin, glucose. Decreased calcium, magnesium, platelets. Abdominal ultrasound, x-ray, or contrast-enhanced computerized tomography (CT) scan.Identifies pancreatitis and related complications, such as pseudocysts and abscesses. Endoscopic retrograde cholangiopancreatography (ERCP)Identifies pancreatic problems, including pancreatitis by visualizing the gastrointestinal tract. Nursing Care: NPO, NG tube, antiemetics, insulin, IV fluids and electrolytes, opioid analgesics, pancreatic enzymes (pancrealipase) with meals/snacks. Progress to bland/low-fat diet. Patient Teaching: No alcohol consumption, encourage Alcoholic Anonymous (AA), no smoking, reduce stress. Complications: Chronic pancreatitis, pancreatic pseudocyst, type I Diabetes.

Which item should the nurse remove from the dinner tray of a patient with cirrhosis?

Bacon Bacon is high in sodium and fat and would not be included in the diet of a patient with cirrhosis.

A patient presents with abdominal pain and jaundice secondary to biliary obstruction related to metastatic incurable cancer in the pancreatic head. The nurse should expect to prepare the patient for which procedure?

Cholecystojejunostomy Rationale: For cancers that cannot be surgically removed, a cholecystojejunostomy is performed to relieve biliary obstruction.

Pancreatic head tumors Whipple procedure/Pancreaticoduodenectomy

Concurrent removal of the: Proximal pancreas and duodenum Distal segment of common bile duct and distal portion of stomach Followed by surgical anastomosis of the: Pancreatic duct Common bile duct Stomach to jejunum

Following assessment of a patient, the nurse notes a bluish discoloration in the periumbilical area. How would the nurse correctly document this finding?

Cullen's sign Cullen's sign is the bluish discoloration in the periumbilical area found in patients with acute pancreatitis. This happens due to blood-stained drainage from the pancreatic autodigestive process.

A patient is seen in the oncology clinic for follow-up after treatment of primary liver cancer with sorafenib. Which finding would indicate an improvement in the patient's status?

Decreased waist size Rationale: Ascites is a collection of fluid in the abdomen and is commonly found in patients with liver cancer. Weight loss and decreased waist size indicate an improvement in the ascites and the patient's status.

Positron emission tomography (PET) scan or PET/CT scan

Determines the stage at time of diagnosis and monitors progress and response to therapy

The nurse is reviewing the current prescriptions for a patient with pancreatitis. Following a recent assessment, the patient was found to have decreased bowel sounds and abdominal distention. Which current medication order would the nurse question for this patient?

Dicyclomine Rationale: Dicyclomine is an anticholinergic drug contraindicated in patients with signs of a paralytic ileus as it can worsen the problem.

During assessment of a patient for suspected cholelithiasis with biliary colic, a positive response to which question posed by the nurse would support the diagnosis?

Do you have pain after consuming a high-fat meal?" Rationale: The pain related to cholelithiasis and biliary colic is often precipitated by consumption of a high-fat meal.

The nurse will also need to monitor for common complications of liver cancer, including:lic

Esophageal bleeds Fluid volume overload Hepatic encephalopathy Malnutrition

Which statement best describes the pathophysiology of acute pancreatitis?

Inflammation activates enzymes, resulting in autodigestion within the pancreas. Rationale: The process of acute pancreatitis involves autodigestion of the pancreas by pancreatic enzymes.

The nurse is providing care to a confused patient with hepatic encephalopathy who refuses to stay in bed and is at risk for falling. Which intervention will the nurse implement to keep the patient safe?

Provide a low bed with the wheels locked. Rationale: The nurse should provide a low bed with locked wheels for a confused patient who refuses to stay in bed. This reduces the risk of injury caused by falls, and helps maintain patient safety.

A patient with advanced pancreatic cancer reports severe abdominal pain and anorexia. Which collaborative care procedure would the nurse expect to prepare for the patient?

External radiation Rationale: Radiation is a collaborative care procedure that can be used to provide symptomatic pain relief for a patient with pancreatic cancer. Depending on their size, tumors can put pressure on nerves. Radiation decreases tumor size.

External Radiation Therapy

External radiation therapy is not effective for treatment of pancreatic cancer, but is sometimes indicated for use as a pain relief measure.

A nurse is caring for a patient who has been diagnosed with cirrhosis; the disease is in the early stages. Which clinical manifestation would the nurse expect the patient to exhibit?

Fatigue The symptoms found in the early stages of cirrhosis include hepatomegaly and fatigue.

A patient presents to the primary care provider one week after hospital discharge for an episode of acute pancreatitis. The patient reports a fever that has lasted for the last few days and stools have had a "really foul smell" and "appear greasy." A finger stick for blood glucose indicates a glucose level of 220 mg/dL. Which does the nurse suspect may be occurring?

Further pancreatic destruction Rationale: The return of steatorrhea, fever, and elevated blood glucose levels indicates that the acute pancreatitis is recurring.

The nurse is caring for a patient who is returning from the endoscopy lab after undergoing an endoscopic retrograde cholangiopancreatography (ERCP). What should the nurse assess before the patient resumes eating?

Gag reflex Rationale: An endoscopy involves application of a numbing spray to the back of the throat to facilitate scope movement down the throat. The nurse should ensure that the patient has an intact gag reflex to prevent aspiration.

The nurse is evaluating a patient in the emergency department for suspected pancreatitis. Which factors, if present in the patient history or current assessment, would increase the risk for pancreatitis?

History of gallstones History of gallstones African American ethnicity 30 pack year history of smoking

Which pathologic change would cue the nurse to assess for excess fluid volume in a patient with cirrhosis?

Hyperaldosteronism The damaged liver is unable to metabolize aldosterone, so it builds up and causes excess fluid volume.

The nurse is preparing to administer spironolactone to a patient with cirrhosis. Which finding would lead the nurse to withhold the dose of spironolactone?

Hyperkalemia

Prevention of Liver Cancer

Identify and treat hepatitis B/C as early as possible. Work with patients who are chronic alcohol abusers about alcohol abstinence. Conduct routine alpha-fetoprotein, CT scans, and ultrasounds of patients with cirrhosis.

Cholecystitis

Inflammation of gallbladder. It is usually caused by cholelithiasis (i.e. gallstones). These gallstones block the cystic or common bile ducts and cause bile to back up into the gallbladder. Risk Factors: Female, high fat diet, obesity, genetics, older age. Symptoms: RUQ pain (possible radiation to right shoulder), pain and n/v with ingestion of high-fat food, jaundice, clay-colored stools, steatorrhea, dark urine, pruritis,, dyspepsia, gas. Labs: Increased WBC, bilirubin (if bile duct blocked), amylase and lipase (if pancreas is involved), AST, and ALP (if common bile duct blocked). Interventions: Lithoripsy (to break up gallstones), cholecystectomy (removal of gallbladder).

Which nursing interventions will be most effective to alleviate nausea and vomiting by decreasing gallbladder stimulation in a patient with cholecystitis?

Insert a nasogastric tube Establish NPO (nothing by mouth) status for the patient

Internal Radiation Therapy

Internal radiation is not used as often as external radiation, but radiation seeds can be implanted into the tumor in some situations as an attempt to eradicate the cancer.

The nurse is caring for a patient who underwent a partial hepatectomy for primary liver cancer a few days ago. Which assessment findings suggest possible complications?

Jaundice The occurrence of jaundice after a partial hepatectomy would suggest possible complications from the procedure, such as an exacerbation of cirrhosis or liver failure. Changes in mental status Changes in mental status after a partial hepatectomy suggest possible complications from the procedure, such as an exacerbation of cirrhosis or liver failure.

Diverticulitis

Labs: Decreased HCT/HGB, Increased WBC Meds: Antibiotics (ex. Metronidazole), analgesics Nursing Care: *Diet: NPO or clear liquid diet during exacerbations, then progress to low-fiber diet. Ogoing, eat high-fiber diet. Avoid seeds, nuts, popcorn. *Monitor for signs of pertitonitis (symptoms; n/v, rigid/boardlike abdomen, rebound tenderness, fever, tachycardia).

Ulcerative Colitis and Crohn's Disease

Labs: Decreased Hct/Hbg and albumin. Increased ESR, CRP, WBC. Risk Factors: Genetics, Caucasians, Jewish descent, stress, autoimmune disorders. Meds: 5-aminosalicylic acid (ex. sulfasalazine), corticosteroids (ex. prednisone), immunosuppressants (ex. cyclosporine), antiadiarrheals (ex. loperamide). Nursing Care: *Monitor for signs of peritonitis (symptoms: n/v, rigid/boardlike abdomen, rebound tenderness, fever, tachycardia). *Monitor I & Os, electrolytes (risk of hypokalemia). *Diet: NPO during exacerbations. Ongoing eat foods high in protein and calories, low in fiber. Avoid caffeine, alcohol. Eat small frequent meals.

Which assessment finding would demonstrate the efficacy of pancreatic enzyme replacement?

No evidence of steatorrhea Rationale: Steatorrhea is caused by fat malabsorption due to an inability to break down fats by the pancreatic enzymes.

The nurse is caring for a patient with diagnosed acute pancreatitis and notes a recent elevation in temperature, a respiratory rate of 28 breaths/minute, and a few crackles in the bases of the lungs. Which actions by the nurse would best address the patient's current situation?

Obtain O2 saturation level The patient with acute pancreatitis may develop atelectasis and pneumonia. This happens because of the location of the pancreas to the diaphragm and when the patient does not take deep breaths, which would be painful. Elevate the bed to semi-Fowler's position Elevating the head of the bed to at least a semi-Fowler's position will lower the diaphragm and make it easier for the patient to breathe. Instruct patient on incentive spirometry use Incentive spirometry use helps open up the alveoli and provide better oxygenation.

Which interventions should the nurse include in the plan of care for a patient with cirrhosis who is experiencing excess fluid volume?

Obtain a daily weight.Measuring the patient's weights every day will determine whether fluid volume is increasing, so this should be included in the plan of care. Auscultate lung sounds.Fluid volume excess may manifest itself as crackles in the lungs. Therefore the nurse should auscultate the patient's lung sounds as part of the plan of care. Elevate lower extremities.The nurse should elevate the lower extremities of a patient who has fluid volume overload, as this will decrease peripheral edema. This should be included in the plan of care.

Which statement made by the patient reflects an understanding of the nurse's instruction regarding the proper use of oral pancreatic enzymes?

Pancreatic enzymes will help with food digestion." Rationale: The patient with pancreatitis will not be able to produce pancreatic enzymes. Therefore, pancreatic enzymes will need to be administered with meals and snacks to facilitate digestion.

The nurse is awaiting orders for a patient being admitted from the emergency room for conservative therapy for pancreatitis. The nurse would include which goals in the plan of care for the newly admitted patient?

Patient will remain free of infection. Antibiotics will be administered to decrease risk of infection. Patient will verbalize understanding of NPO status. The patient needs to maintain NPO status in order to suppress pancreatic enzymes. Fluid and electrolyte levels are within normal limits. Fluid shifts from the vascular compartment to the peritoneal cavity leading to shock. Patient will rate pain at less than 2 in a 24-hour period. A pain level of a 2 is minimal and shows the patient is achieving pain relief.

Cholecystojejunostomy

Performed to relieve biliary obstruction and/or place biliary stents Performed if surgical removal is not possible

A patient in the recovery room after laparoscopic cholecystectomy reports severe bloating and abdominal discomfort. Which nursing intervention would best address this patient's concern?

Place the patient in the Sims' position Rationale: Bloating and abdominal discomfort are common after a laparoscopic cholecystectomy because of the carbon dioxide used by the health care provider to visualize the abdominal cavity during the procedure. The Sims' position helps move the gas pocket away from the diaphragm.

CT scan

Provides information on tumor metastasis and vascular involvement; is often the first study conducted

Cholecystectomy

Removal of gallbladder. If done via laparoscopic approach, shoulder pain is expected (encourage ambulation to reduce free air pain). If done via open approach, T-tube may be placed in bile duct. Nursing care of T-tube: ***Record drainage > 400ml expected in first 24hours, then will gradually decrease. Drainage > 1000ml/day needs to be reported. ***Empty drainage bag every 8 hours. ***Clamp tube for 1-2 hours to assess for tolerance to eating prior to removal. ***After removal, stools should return to brown color in about 1 week. Patient Teaching: low fat diet, avoid gas-causing foods, lose weight Complication:: Pancreatitis, peritonitis r/t rupture of gallbladder.

A patient being treated for pancreatitis says to the nurse, "I thought nitroglycerin was only given for chest pain." Which explanation provided by the nurse best addresses this statement?

Some antispasmodic medications can cause chest pain, so we give nitroglycerin to relax smooth muscle." Rationale: Nitroglycerin may be administered to relax smooth muscle and, in turn, decrease muscle spasms and control pain.

Which instructions regarding home management should the nurse include when preparing a patient with chronic pancreatitis for discharge? Select all that apply.

Take insulin as prescribed Self-monitor blood glucose levels Stop smoking cigarettes and tobacco products

The caregiver of a patient with suspected pancreatitis asks the nurse why both serum amylase and serum lipase tests are being done if they are both enzymes related to the pancreas. Which explanation by the nurse accurately explains why both are being done?

The serum amylase can be high due to other causes, so we also run the serum lipase." Rationale: The serum amylase can rise as a result of mumps, cerebral trauma, or a kidney transplant. When both lipase and amylase are elevated, this indicates acute pancreatitis.

Liver Cancer

These early signs can include: Splenomegaly Hepatomegaly Fatigue Peripheral edema Ascites Portal hypertension Patients with later stages of liver cancer will present with: Anorexia Weight loss Fever/chills Jaundice Palpable mass Right upper quadrant tenderness Diagnostic testing Imaging studies are performed first, and biopsies are done when MRI, CT scans, or other imaging studies are inconclusive or a sample of the tissue is needed to direct treatment. When the health care provider suspects that a patient has liver cancer, imaging studies such as an MRI or CT scan are done first. Needle biopsies are done when the imaging studies are inconclusive or a tissue sample is needed to direct treatment. Biopsies are not done very often, because they increase the risk of spreading cancer cells through the needle tract created from the biopsy needle. Serum alpha-fetoprotein levels are increased in only about 60% of patients with liver cancer, so this laboratory result alone does not confirm a diagnosis of liver cancer.

Which is the rationale behind the primary health care provider ordering an endoscopic ultrasound (EUS) for a patient admitted with suspected pancreatic cancer?

To view the pancreas and obtain a biopsy of the tumor Rationale: EUS allows the user to see the pancreas via the endoscope and makes it easy to obtain a fine-needle aspiration of the tumor for pathologic examination.

Treatment of Liver Cancer

Treatment of primary liver cancer depends on several factors that include: Stage of the cancer Number, size, and location of tumor Age General health Blood vessel involvement Extent of underlying liver disease ****Partial Hepatectomy=surgical removal of a portion of the liver *****Liver Transplantation *****Transarterial Embolization= procedures are performed by an interventional radiologist. A catheter is inserted into the femoral or radial artery and guided to the blood supply of the tumor. Either a chemical or radiation is injected to the blood supply of the tumor. *****Targeted Chemotherapy=The drug used for targeted therapy is a kinase inhibitor called sorafenib. This blocks certain proteins needed for cancer cell replication.

A patient has been recently diagnosed with late-stage pancreatic cancer. The family tells the nurse they do not understand how this could happen as the patient never showed signs of cancer or complained of pain. Which would be the best response by the nurse?

Tumors that start in the tail of the pancreas do not show symptoms until the cancer has already progressed and spread." Rationale: The tumor most likely originated in the tail of the pancreas, these are often silent tumors until they are very advanced

What should the nurse include in the teaching for a patient with cirrhosis who has an elevated prothrombin time (PT)/international normalized ratio (INR)?

Use an electric razor for shaving. Rationale: The elevated PT/INR indicates that the patient is at risk for bleeding. Cirrhosis damages the liver and prevents clotting factors from being formed.

A nurse is caring for a patient with a long-standing history of cirrhosis. Which findings on admission would cue the nurse to ask for further information from the patient or caregiver? Correct

Uses acetaminophen for pain Lethargic and oriented to person Consumes 1 to 2 alcoholic beverages per week

A female patient scheduled for a laparoscopic cholecystectomy tells the nurse she is frightened because she has heard from others that the abdominal distention and pain after the surgery are severe. Which care team recommendation will best help alleviate distention?

We will help you walk in the hall to decrease distention." Rationale: Ambulation helps dissipate the carbon dioxide introduced during the surgical procedure. The patient should be assisted, since she will be recovering from surgery.

Pancreatic cancer

has an insidious onset and is frequently undetected until the disease has progressed

Side effects of chemotherapy include

nausea, vomiting, diarrhea, and pancytopenia. The nurse will monitor and correct fluid and electrolyte imbalances related to gastrointestinal losses. The nurse should also assess for signs and symptoms of infection, bleeding, and anemia related to the pancytopenia if the patient is receiving chemotherapy. Radiation therapy is used to relieve pain from cancerous tumors that have extended to retroperitoneal and nerve plexuses. Radiation therapy is used to relieve pain from cancerous tumors that have extended to retroperitoneal and nerve plexuses. It is also used to decrease tumor size and can relieve biliary duct obstruction and effectively manage symptoms of pancreatic cancer. It is important for the nurse to assess the skin at, and around, the radiated site as the skin can become reddened and break down from repeated radiation treatments.