Liver, Pancreas & Biliary Tract Problems

A patient has undergone cholecystectomy. What postoperative care should the nurse perform for this patient? Select all that apply.

After cholecystectomy, it is important to follow dietary restrictions. A diet low in fat decreases the workload of the liver. Bleeding is a complication after the procedure; hence the nurse should monitor it. It is important to position the patient in Sims' position to facilitate gas pockets moving away from the diaphragm. Encourage deep breathing along with movement and ambulation to help expand the lungs and promote ventilation. The patient need not be put in shock position; it does not contribute to recovery.

When planning care for a patient with cirrhosis, the nurse will give highest priority to which nursing diagnosis?

Although all of these nursing diagnoses are appropriate and important in the care of a patient with cirrhosis, airway and breathing are always the highest priority. Impaired skin integrity, imbalanced nutrition, and excess fluid volume are all seen in patients with cirrhosis, but they are not priorities at this time.

When providing discharge teaching for the patient after a laparoscopic cholecystectomy, what information should the nurse include?

Although the usual diet can be resumed, a low-fat diet usually is better tolerated for several weeks following surgery. Normal activities can be resumed gradually as the patient tolerates. Bile-colored drainage or pus, redness, swelling, severe pain, and fever may all indicate infection. The bandage may be removed the day after surgery and the patient can shower.

A patient with cholelithiasis needs to have the gallbladder removed. Which patient assessment is a contraindication for a cholecystectomy?

An aPTT of 54 seconds is above normal and indicates insufficient clotting ability. If the patient had surgery, significant bleeding complications postoperatively are very likely. Fluids can be given to eliminate the dehydration, the abscess can be assessed, and the obstructions in the cystic and common bile duct would be relieved with the cholecystectomy .

The patient with cirrhosis has an increased abdominal girth from ascites. The nurse should know that this fluid gathers in the abdomen for which reasons? Select all that apply.

Ascites related to cirrhosis is caused by decreased colloid oncotic pressure from the lack of albumin due to the liver's inability to synthesize it and the portal hypertension that shifts protein from the blood vessels to the peritoneal cavity, and hyperaldosteronism, which increases sodium and fluid retention. The intake of fluids orally and the removal of blood cells by the spleen do not contribute directly to ascites.

A patient has an increased ammonia level associated with hepatic encephalopathy. What assessment finding does the nurse expect?

Asterixis is a twitching spasm of the hands and wrists seen in patients with increased ammonia levels in conditions such as hepatic encephalopathy. Aphasia, hyperactivity, and acute dementia are manifestations not associated with hepatic encephalopathy. Besides asterixis, an increased serum ammonia level causes sedation and confusion that progress to a comatose state.

When caring for a patient with a biliary obstruction, the nurse will anticipate administering which vitamin supplements? Select all that apply.

Biliary obstruction prevents bile from entering the small intestine and thus prevents the absorption of fat-soluble vitamins. Vitamins A, D, E, and K are all fat soluble and thus would need to be supplemented in a patient with biliary obstruction. Vitamin B is water soluble and would not be recommended for a patient with biliary obstruction.

A patient is diagnosed with acute pancreatitis. When providing dietary teaching, what are the points that a nurse should tell the patient? Select all that apply.

Consuming a low-fat, high-carbohydrate diet is essential in pancreatitis. Fats should be avoided because they stimulate the secretion of cholecystokinin, which then stimulates the pancreas. Alcohol is an irritant and must be avoided. Carbohydrates are less stimulating to the pancreas and are encouraged. Fluid intake should be increased to prevent dehydration.

A patient with cancer that has metastasized to the liver manifests symptoms of fluid retention, including edema and ascites. To determine the effectiveness of the diuretic therapy that has been prescribed, what should the nurse assess?

Daily measurement of the abdominal girth provides a direct indication of ascitic fluid increase or decrease. Breath and bowel sounds are usually not affected by liver metastasis until the late stages, when fluid overload and multisystem organ involvement occur. Reviewing the results of the most recent blood work will not show direct measurement of the effectiveness of diuretic therapy.

A nurse is attending to a patient suffering from cirrhosis of the liver. What clinical manifestations should the nurse expect to find upon physical examination? Select all that apply.

Ecchymoses are small areas of bleeding into the skin or mucous membrane forming blue or purple patches. Because there is decreased synthesis of prothrombin in the liver, the bleeding and clotting time may be deranged. Telangiectasia is a vascular lesion formed by a group of small blood vessels. Spider angioma is also seen in cirrhosis of the liver. Vitiligo (white patches of skin) develops from destruction of melanocytes and is not related to cirrhosis. Melanosis is the deposit of dark pigment unrelated to cirrhosis.

The nurse provides discharge instructions to a patient with newly diagnosed cirrhosis. Which statement made by the patient indicates the need for further teaching?

Even though a low-protein diet has been questioned in the treatment of patients with cirrhosis, it remains in use. In light of this, it is incorrect for the patient to say that he may eat anything. Patients with cirrhosis must also avoid alcohol. Frequent rest and limitation of medications to those that have been prescribed are appropriate resolutions in a newly diagnosed case of cirrhosis and therefore do not indicate the need for further teaching.

A patient suffering from cholelithiasis underwent a cholecystectomy. What dietary advice will the nurse give this patient? Select all that apply.

Having a high-fiber diet helps in the smoother passage of stools and prevents constipation. Having small and frequent meals helps digestion and prevents nausea. Fats make it harder to digest. After cholecystectomy, it is essential that the patient has an adequate intake of water, around 2500-3000 mL per day. The patient should not have the usual foods that he/she used to consume; modifications are needed to facilitate easy digestion of food in the absence of the gall bladder.

A patient underwent pancreaticoduodenectomy (Whipple procedure) for pancreatic cancer. What are the instructions that the nurse should include when giving dietary advice to this patient? Select all that apply.

Having a low-fat, high-carbohydrate, and high-protein diet is essential. The diet should be low in fat to decrease the work load of the liver and promote healing. A high-calorie diet should be provided, as more energy is required. High-calorie meals are needed for energy and to promote the use of protein for tissue repair. A high-protein diet is required for tissue building. The diet should be high in carbohydrates to provide the required energy. The patient should not resume a normal diet and should follow the restrictions as advised.

A patient with cirrhosis of the liver is admitted to the hospital. What hematologic symptoms might be noted in this patient? Select all that apply.

Hematologic problems include thrombocytopenia, leukopenia, anemia, and coagulation disorders. Anemia, leukopenia, and thrombocytopenia are probably caused by the splenomegaly that results from the backup of blood from the portal vein into the spleen (portal hypertension). Overactivity of the enlarged spleen results in increased removal of blood cells from circulation. Anemia is also due to inadequate red blood cell (RBC) production and survival, poor diet, poor absorption of folic acid, and bleeding from varices. Leukemia and polycythemia vera are not caused by cirrhosis.

The nurse finds that a patient admitted to the hospital with cirrhosis of the liver is disoriented, lethargic, and drowsy and has abnormal reflexes. Based on the patient's signs and symptoms, the nurse understands that the patient is in grade ___ hepatic encephalopathy. Fill in the blank using a whole number.

Hepatic encephalopathy has 0 to 4 grades based on three factors: level of consciousness, intellectual function, and neurological findings. Grade 2 is characterized by lethargy, drowsiness, and inappropriate behavior (level of consciousness); disorientation (intellectual function); and asterixis and abnormal reflexes (neurological findings). Grade 1 is characterized by a short attention span, mild confusion, and depression. Grade 3 is characterized by loss of meaningful conversation, marked confusion, and incomprehensible speech. Grade 4 is characterized by a complete lack of intellectual function. Grade 0 is characterized by insomnia, sleep disturbances, and a subtle change in computational skills.

The health care provider prescribes lactulose for a patient with hepatic encephalopathy. The nurse will monitor for effectiveness of this medication for this patient by assessing what?

Hepatic encephalopathy is a complication of liver disease and is associated with elevated serum ammonia levels. Lactulose traps ammonia in the intestinal tract. Its laxative effect then expels the ammonia from the colon, resulting in decreased serum ammonia levels and correction of hepatic encephalopathy. Lactulose does not relieve constipation or abdominal pain or decrease liver enzymes.

A nurse is collecting data from a patient admitted with hepatitis A. Which information given by the patient may indicate the patient's susceptibility to contract hepatitis A? Select all that apply.

Hepatitis A spreads mainly through the fecal-oral route. People living in slums are also exposed to the virus, as food stuffs may be contaminated. Sewage may harbor this virus; hence sewage cleaners and plumbers may be exposed to it. Working as a waiter, dishwasher, or in a chemical factory does not expose the patient to the virus.

What are the precautions that nurses and hospital staff should follow while handling patients suffering from hepatitis infections? Select all that apply.

Hepatitis A spreads through the fecal-oral route, and hepatitis B spreads through blood. Hence the virus can spread through needles and syringes used by the patient. Also, the virus can spread while the nurse is handling the urine or fecal material of the patient; hence it is necessary to wear gloves. Hepatitis does not spread through air; hence a mask is not required. A private room is required in respiratory diseases, not in hepatitis.

The parent of a pediatric patient suffering from hepatitis A approaches the nurse and is worried about the spread of infection to other family members through use of the same bathroom. What should the nurse advise the patient's parent? Select all that apply.

Hepatitis A spreads through the fecal-oral route. Transmission is prevented by maintaining hygiene. Proper hand washing is extremely important in preventing the spread of the virus. Buying a separate commode is unnecessary. Thorough cleaning of the bathroom and all the equipment is enough to limit spread of the virus. Use of disposable toilet sheets is not sufficient to prevent spread of the virus.

What points should a nurse emphasize while teaching a patient ways to protect oneself from exposure to hepatitis B infection? Select all that apply.

Hepatitis B spreads through sexual contact and through blood. Sharing razors or toothbrushes with an infected person may introduce infection in another person's body. Similarly, a needle used by an infected person can spread the infection. Hepatitis B also spreads via sexual exposure with an infected person. Using a condom gives some protection against the spread of infection. Hepatitis B doesn't spread through water and food. Hepatitis B doesn't spread with general casual contact.

A patient suffering from ascites is admitted to the hospital. What are the factors that can lead to ascites development? Select all that apply.

Hyperaldosteronism or increased secretion of aldosterone causes ascites. Portal hypertension causes an increase in resistance to blood flow in the liver leading to ascites. When there is decreased serum colloidal oncotic pressure, there is impairment of synthesis of albumin and loss of albumin in the peritoneal cavity. It leads to ascites. Diabetes is a metabolic syndrome and does not cause ascites. Increased flow of hepatic lymph, not decreased flow, leads to ascites.

The patient with sudden pain in the left upper quadrant radiating to the back and vomiting was diagnosed with acute pancreatitis. What intervention should the nurse expect to include in the patient's plan of care?

Initial treatment with acute pancreatitis will include an NG tube if there is vomiting and being NPO to decrease pancreatic enzyme stimulation and allow the pancreas to rest and heal. Fluid will be administered to treat or prevent shock. Enteral feedings will be used only for the patient with severe acute pancreatitis in whom oral intake is not resumed. Antibiotic therapy is needed only with acute necrotizing pancreatitis and signs of infection. The pain will be treated with IV morphine because of the NPO status.

The family of a patient newly diagnosed with hepatitis A asks the nurse what they can do to prevent becoming ill themselves. Which response by the nurse is most appropriate?

Immunoglobulin provides temporary (one to two months) passive immunity and is effective for preventing hepatitis A if given within two weeks after exposure. It may not prevent infection in all persons, but it will at least modify the illness to a subclinical infection. The hepatitis vaccine is used only for preexposure prophylaxis

A patient with liver cancer is scheduled to receive radiofrequency ablation (RFA) therapy. The nurse knows that this treatment is appropriate for which of these?

In RFA, a thin needle is inserted into the core of the tumor. The electrical energy is used to create heat in a specific location for a limited time. The end result is destruction of tumor cells. This procedure can be done percutaneously, laparoscopically, or through an open incision. RFA can be used to treat tumors that are less than 5 cm in size and for palliative purposes. RFA is not effective in tumors over 6 cm or metastatic cancer. Alcohol injection is used for tumors that are less than 3 cm in size.

A patient has been admitted with diabetes mellitus, malnutrition, osteomyelitis, and alcohol abuse. Laboratory results are significant for an alanine aminotransferase (ALT) of 198 IU/L and aspartate transaminase (AST) of 224 IU/L. Which diagnosis does the nurse attribute these findings to?

In the patient with alcohol abuse, liver disease could develop as a complication, increasing the liver function tests above the normal levels. Normal ALT range is 7--56 IU/L and normal AST range is 5--40 IU/L. Diabetes would result in elevated blood sugar levels. Malnutrition would be evidenced by low protein levels. Osteomyelitis is an infection of the bone, which would result in an elevated white blood cell count.

The patient with advanced cirrhosis asks why his or her skin is so yellow. The nurse's response is based on the knowledge that

Jaundice results from the functional derangement of liver cells and compression of bile ducts by connective tissue overgrowth. Jaundice occurs as a result of the decreased ability to conjugate and excrete bilirubin Jaundice is not caused by a build-up of bile salts, a lack of clotting factors, or decreased colloidal oncotic pressure.

A patient with ascites is admitted to the hospital. What should be the primary nursing actions in this case? Select all that apply.

Management of ascites focuses on sodium restriction, diuretics, and fluid removal. The fluid and electrolytes should be closely monitored; an imbalance may lead to an increase in ascites. An albumin infusion may be used to help maintain intravascular volume and adequate urine output by increasing plasma colloid osmotic pressure. Paracentesis can be done to remove the ascitic fluid from the peritoneum. The amount of sodium restriction is based on the degree of ascites. The patient is usually not on restricted fluids unless severe ascites develops; however, high-fluid intake should be avoided.

A patient with type 2 diabetes mellitus has been diagnosed with nonalcoholic fatty liver disease (NAFLD). The nursing teaching plan should include which of the following?

NAFLD can progress to liver cirrhosis. There is no definitive treatment, and therapy is directed at reduction of risk factors, which include treatment of diabetes, reduction in body weight, and elimination of harmful medications. For those who are overweight, weight reduction is important. Weight loss improves insulin sensitivity and reduces liver enzyme levels. NAFLD does not show up positive on a genetic test. It is not recommended to completely eliminate carbohydrates from the diet. NAFLD is not caused by alcohol, and the question does not imply the patient drinks.

The nurse evaluates the effectiveness of a paracentesis in a patient who has ascites. Which measurement is most important for the nurse to note?

Paracentesis involves the removal of fluid from the abdominal cavity. A large-bore needle connected to tubing is inserted by the healthcare provider into the distended abdomen. The other end of the tubing also has a large-bore needle, which is inserted into a vacuum bottle. The vacuum bottle is then held below the level of the abdomen, facilitating gravity-flowed removal of the ascites. Several bottles of fluid can be removed, with the result measured by reduction in abdominal girth. Cardiac output may improve after paracentesis, but it is unlikely that this measurement needs to be recorded. Paracentesis has no major effect on blood pressure. Likewise, intake and output continues to be monitored to account for the paracentesis fluid but is not as informative as abdominal girth.

The patient with right upper quadrant abdominal pain has an abdominal ultrasound that reveals cholelithiasis. What should the nurse expect to do for this patient?

Patients with cholelithiasis can have severe pain, so controlling pain is important until the problem can be treated. Nothing by mouth status may be needed if the patient will have surgery, but will not be used for all patients with cholelithiasis. Enteral feedings should not be needed and avoiding dietary cholesterol is not used to treat cholelithiasis.

A patient with pancreatic cancer is in the outpatient cancer center to receive radiation therapy. The nurse knows that radiation therapy for patients with pancreatic cancer is to:

Radiation therapy alone for pancreatic cancer has little effect on survival, but may be effective for pain relief. Radiation therapy does not reduce ascites, increase survival time, or inhibit tumor metastasis to other areas of the body.

A patient with a 3-year history of liver cirrhosis is hospitalized for treatment of recently diagnosed esophageal varices. What is the most important information for the nurse to include in the teaching plan for this patient?

Straining during a bowel movement increases venous pressure and could cause rupture of the varices. Fluid restrictions may be a recommendation for ascites but are not directly associated with esophageal varices. If the patient is able to eat, meals should be soft or liquid and the patient should be instructed to eat slowly and avoid extremes in food temperature to prevent irritation. Excessive exercise and activity should be avoided in a patient with esophageal varices to prevent hypertension, however, avoiding straining and other activities that cause the Valsalva maneuver is still a higher-priority recommendation.

A nurse assessing a patient with pancreatitis suspects the presence of Grey Turner sign when the patient exhibits:

The Grey Turner sign includes a bluish discoloration, or ecchymosis, on the left or right flank area, the result of internal bleeding caused by pancreatitis. Jaundice of the sclera is associated with liver disorders and with increased serum bilirubin. Bluish discoloration of the periumbilical area is also seen in bleeding associated with pancreatitis and is known as the Cullen sign. Left abdominal pain that occurs with movement may be seen with pancreatitis but is not associated with the Grey Turner sign.

A patient with hepatitis A is in the acute phase. The nurse plans care while anticipating that the patient may be experiencing which symptoms? Select all that apply.

The acute phase of hepatitis usually lasts from one to four months. During the incubation period, symptoms may include malaise, anorexia and weight loss, fatigue, nausea, occasional vomiting, and abdominal (right upper quadrant) discomfort. The patient may find food repugnant, and smokers may have distaste for cigarettes. There is also a decreased sense of smell. Other symptoms may include headache, low-grade fever, arthralgias, and skin rashes. Pruritus (intense chronic itching) sometimes accompanies jaundice. The pruritus occurs as a result of the accumulation of bile salts beneath the skin. Dizziness and constipation are not symptoms of the acute phase of hepatitis A.

A patient who has hepatitis B surface antigen (HBsAg) in the serum is being discharged with pain medication after knee surgery. Which medication prescription should the nurse question because it is most likely to cause hepatic complications?

The analgesic with acetaminophen should be questioned because this patient is a chronic carrier of hepatitis B and is likely to have impaired liver function. Acetaminophen is not suitable for this patient because it is converted to a toxic metabolite in the liver after absorption, increasing the risk of hepatocellular damage. Tramadol, hydromorphone, and oxycodone with aspirin are less likely to cause complications than acetaminophen.

A patient who underwent a cholecystectomy is now complaining of pain referred to his right shoulder. What is the most probable cause for this pain? Select all that apply.

The carbon dioxide that is used to inflate the abdomen during surgery may not be released or absorbed by the body and can irritate the phrenic nerve and diaphragm. This is the reason for breathing difficulty and the most common cause of shoulder pain following a cholecystectomy. Other conditions, such as myocardial infarction, pericarditis after surgery, and a gallstone left in the gall bladder, may also cause shoulder pain but are less common causes of right shoulder pain in this situation.

The nurse cares for a patient with advanced cirrhosis. What indicates that the patient is experiencing a serious complication?

The liver produces clotting factors. As cirrhosis becomes more advanced, the production of clotting factors is disrupted and thereby decreased, making the patient more susceptible to bleeding. Increasing frequency and severity of nosebleeds and bruising would indicate a deterioration in liver function. Urine retention, abnormal blood glucose, and constipation are not directly associated with advanced cirrhosis.

When teaching the male patient with acute hepatitis C (HCV), the patient demonstrates understanding when the patient makes which statement?

The majority of patients who acquire HCV usually develop chronic infection, which may lead to cirrhosis or liver cancer. HCV is not transmitted via saliva, but percutaneously and via high-risk sexual activity exposure. The treatment for acute viral hepatitis focuses on resting the body and adequate nutrition for liver regeneration. Adofevir is taken for severe hepatitis B (HBV) with liver failure. Chronic HCV is treated with pegylated interferon with ribavirin. Immunity with HCV does not occur as it does with hepatitis A virus (HAV) and HBV, so the patient may be reinfected with another type of HCV.

A patient with cirrhosis of the liver has ascites and is being prepared for a paracentesis. What instructions should the nurse give the patient?

The nurse should instruct the patient to void prior to the paracentesis to prevent accidental puncture of the bladder. During the procedure, the patient sits on the side of the bed or is placed in high Fowler's position. There is no need to keep the patient on NPO status (taking nothing by mouth) or to restrict fluid intake.

Which clinical manifestation of pain does the nurse expect to identify in a patient who has cholecystitis?

The pain of cholecystitis is in the region of the gallbladder (right upper quadrant), which is inflamed as a result of infection and irritation from bile. The pain may be referred to the right shoulder and scapula. Left flank pain with intermittent exacerbations may be caused by renal calculi. Right lower quadrant pain with rebound tenderness may be related to acute appendicitis, Crohn's disease, or peritonitis. Epigastric pain that intensifies when the patient is lying down may be related to gastroesophageal reflux disease or hiatal hernia.

A patient has just undergone a liver transplant and is now in the intensive care unit (ICU). What nursing interventions are appropriate for this patient to prevent respiratory complications? Select all that apply.

The patient who has had a liver transplant requires highly skilled nursing care in an ICU or another specialized unit. To prevent respiratory complications, the patient should be encouraged to use measures such as coughing, deep breathing, and repositioning. Administering cough suppressants would be counterproductive to recovery. The patient can be ambulated later, when the condition is stable.

Following a laparoscopic cholecystectomy, a patient without pre- or postoperative complications is being discharged from the hospital. What instructions should the nurse include in the discharge teaching? Select all that apply.

The patient who undergoes a laparoscopic cholecystectomy without complications may be discharged shortly after surgery. Therefore, it is important to teach the patient about care following discharge. The patient should be informed that he or she may take a shower. Normal activities can be resumed the next day, and the patient may return to work within 1 week of surgery. A normal diet can also be resumed, but a low-fat diet is recommended for several weeks after surgery. The patient should immediately notify the surgeon if there is redness, swelling, bile-colored drainage, or pus from any incision; severe abdominal pain; nausea; vomiting; and/or fever and chills.

The nurse suspects that a patient has hepatitis A. Which symptom will the patient most likely report developed first?

The preicteric phase of hepatitis is usually marked by severe anorexia, malaise, and fever. Itching and jaundice appear later in the hepatitis disease process in a stage known as the icteric phase. Ascites may develop as a long-term effect of diffuse liver damage.

A nurse is attending to a patient with jaundice. The health care provider instructs the nurse to prepare the patient for percutaneous liver biopsy. The nurse understands that presence of certain conditions may need the procedure to be rescheduled. Which conditions may require percutaneous liver biopsy to be rescheduled? Select all that apply.

To do a liver biopsy when a patient has marked ascites increases the risk of leakage of ascitic fluid. The liver biopsy should be postponed. A patient with low hemoglobin levels should not have a liver biopsy because the patient cannot take the risk of the puncture of a hepatic blood vessel. A patient with bleeding disorder may not be an appropriate candidate for liver biopsy due to the increased risk of bleeding. Chronic hepatitis is not a reason to postpone a liver biopsy; in fact, it is an indication for liver biopsy. A diagnosis of hepatic cirrhosis is not a reason to postpone a liver biopsy because it is done to detect the presence of hepatic cirrhosis.

A patient with cancer of the head of the pancreas is admitted to the hospital. What are the manifestations that a nurse might expect to find in this patient? Select all that apply.

Tumor of the head of the pancreas will obstruct the common bile duct where it passes through the head of the pancreas to join the pancreatic duct and empty at the ampulla of Vater into the duodenum. The stools will be clay-colored when bile is not able to enter the duodenum. Pruritus is also a common symptom in cancer of the pancreas; hence the patient may complain of itching and irritation of the skin. Severe pain is also present. The pain generally depends on the part affected and severity. Edema and ulcers are not common manifestations of pancreatic cancer.

When caring for a patient with liver disease, the nurse recognizes the need to prevent bleeding resulting from altered clotting factors and rupture of varices. Which nursing interventions would be appropriate to achieve this outcome? Select all that apply.

Using the smallest gauge needle for injections will minimize the risk of bleeding into the tissues. Avoiding straining, nose blowing, and coughing will reduce the risk of hemorrhage at these sites. The use of a soft-bristle toothbrush and avoidance of irritating food will reduce injury to highly vascular mucous membranes. Aspirin and NSAIDS should be avoided because they can increase bleeding in ruptured varices. The nurse should apply gentle but prolonged pressure to venipuncture sites to minimize the risk of bleeding. Aspirin and NSAIDs should not be used in patients with liver disease because they interfere with platelet aggregation, thus increasing the risk for bleeding.