Problems of the Biliary Tract & Pancreas

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A. obesity

A nurse is reviewing risk factors with a client who has cholecystitis. The nurse should identify that which of the following is a risk factor for cholecystitis? A. obesity B. Rapid weight gain C. Decreased blood triglyceride level D. Male sex

D. Increased blood glucose level

A nurse is reviewing the admission laboratory results of a client who has acute pancreatitis. Which of the following findings should the nurse expect? A. Decreased blood lipase level B. Decreased blood amylase level C. Increased blood calcium level D. Increased blood glucose level

C. Direct bilirubin 2.1 mg/dL

A nurse in a clinic is reviewing the laboratory reports of a client who has suspected cholelithiasis. Which of the following is an expected finding? A. blood amylase 80 units/L B. WBC 9,000 C. Direct bilirubin 2.1 mg/dL D. Alkaline phosphatase 25 units/L

C. Gray-blue discoloration of the skin around the umbilicus

A nurse is assessing a client who has pancreatitis. Which of the following findings should the nurse identify as a manifestation of pancreatitis? A. Generalized cyanosis B. Hyperactive bowel sounds C. Gray-blue discoloration of the skin around the umbilicus D. Wheezing in lower lung fields

D. Epigastric pain radiating to the left shoulder

A nurse is completing an admission assessment of a client who has pancreatitis. Which of the following findings should the nurse expect? A. Pain in right upper quadrant radiating to right shoulder B. Report of pain being worse when sitting upright C. Pain relieved with defecation D. Epigastric pain radiating to the left shoulder

A. "I plan to eat small, frequent meals." B. "I will eat easy‑to‑digest foods with limited spice." C. "I will use skim milk when cooking."

A nurse is completing nutrition teaching for a client who has pancreatitis. Which of the following statements by the client indicates an understanding of the teaching? (Select all that apply.) A. "I plan to eat small, frequent meals." B. "I will eat easy‑to‑digest foods with limited spice." C. "I will use skim milk when cooking." D. "I plan to drink regular cola." E. "I will limit alcohol intake to two drinks per day."

B. " You might have shoulder pain after surgery"

A nurse is completing preoperative teaching for a client who is scheduled for a laparoscopic cholecystectomy. Which of the following should be included in the teaching? A. "The scope will be passed through your rectum." B. " You might have shoulder pain after surgery" C. "You will have a Jackson-Pratt drain in place after surgery." D. "You should limit how often you walk for 1-2 weeks."

B. Offer a glass of water following medication administration.

A nurse is preparing to administer pancrelipase to a client who has pancreatitis. Which of the following actions should the nurse take? A. Instruct the client to chew the medication before swallowing. B. Offer a glass of water following medication administration. C. Administer the medication 30 min before meals. D. Sprinkle the contents on peanut butter.

B. Resume a diet of choice C. Cleanse the puncture site using mild soap and water E. Report nausea and vomiting to the surgeon

A nurse is providing discharge teaching to a client following a laparoscopic cholecystectomy. Which of the following instructions should the nurse include in the teaching? (SATA) A. Take baths rather than showers. B. Resume a diet of choice C. Cleanse the puncture site using mild soap and water D. Remove the adhesive strips from the puncture site in 24 hours E. Report nausea and vomiting to the surgeon

D. This medication dissolves gallstones gradually over a period of two years

A nurse is reviewing a new prescription for Chenodiol with a client who has Cholelithiasis. Which of the following information should the nurse include in the teaching? A. the medication is used to decrease biliary pain B. this medication requires thyroid function monitoring every 6 months C. This medication is not recommended for clients with diabetes mellitus D. This medication dissolves gallstones gradually over a period of two years

necrotizing hemorrhagic pancreatitis (NHP)

Acute Pancreatitis · Acute Pancreatitis is a serious (and sometimes life-threatening) inflammation of the pancreas. This process (which affects immunity) is caused by a premature activation of excessive pancreatic enzymes that destroy ductal tissue and pancreatic cells, resulting in autodigestion and fibrosis of the pancreas § The severity depends on the extent of inflammation and tissue damage § Acute Pancreatitis can range from mild involvement evidenced by edema and inflammation to _____________________________, which is characterized by diffusely bleeding pancreatic tissue with fibrosis and tissue death · The Pancreas is unusual in that it functions as both an exocrine gland and an endocrine gland. (Endocrine disorder is diabetes mellitus) § The exocrine function of the pancreas is responsible for secreting enzymes that assist in the breakdown of starches, proteins, and fats. These are normally secreted in inactive form and become activated once they enter the small intestine · EARLY ACTIVATION (in the pancreas, not small intestine) results in the inflammatory process of pancreatitis § Direct toxic injury to pancreatic cells and production/release of pancreatic enzymes (trypsin, lipase, elastase) result from obstructive damage. After pancreatic duct obstruction, increased pressure may result in ductal rupture, allowing spillage of trypsin and other enzymes into the pancreatic parenchymal tissue (results in autodigestion of pancreatic tissue) § In Acute Pancreatitis, four major pathophysiologic processes occur: · Lipolysis · Proteolysis · Necrosis of blood vessels · Inflammation § The hallmark of pancreatic necrosis is enzymatic fat necrosis of the endocrine and exocrine cells of the pancreas caused by lipase. Fatty acids are released during the lipolytic process and combine with ionized calcium to form a soap-like product · The initial rapid lowering of serum calcium levels is not compensated by the parathyroid gland. Hypocalcemia occurs § Proteolysis involves the splitting of proteins by hydrolysis of the peptide bonds, resulting in the formation of smaller polypeptides. Proteolytic activity may lead to thrombosis and gangrene of the pancreas (can be localized or involve entire organ) § Elastase is activated by trypsin and causes elastic fibers of the blood vessels and ducts to dissolve. The necrosis of blood vessels results in bleeding (ranging from minor bleeding to massive hemorrhage of pancreatic tissue). Kallikrein (a pancreatic enzyme) causes release of enzymes that contribute to vasodilation and increased vascular permeability, further compounding the hemorrhagic process. · This massive destruction of blood vessels by necrosis may lead to generalized hemorrhage, with blood escaping into the retroperitoneal tissues · The ultimate impact to a patient's immunity occurs in the presence of hemorrhagic pancreatitis. The patient with this disorder is critically ill, and extensive pancreatic destruction and shock may lead to death. The majority of deaths from acute pancreatitis result from irreversible shock § A secondary inflammatory stage occurs when leukocytes cluster around the hemorrhagic and necrotic areas. A secondary bacterial process can lead to suppuration (pus formation) of the pancreatic parenchyma or the formation of an abscess. Mild lesions can be absorbed, while severe lesions cause calcification and fibrosis (forming a pancreatic pseudocyst)

1. Severe ABD pain in the MID-EPIGASTRIC AREA or LEFT UPPER QUADRANT 2. Pain has sudden onset and RADIATES TO THE BACK, LEFT FLANK, OR LEFT SHOULDER 3. Pain is intense, boring (feeling of going through body), and continuous and is worsened by lying in supine position. 4. Pain relief when lying in fetal position or by sitting upright and bending forward 5. Weight loss from nausea and vomiting 6. Generalized jaundice 7. CULLEN's Sign: Gray-blue discoloration of the ABD and periumbilical area 8. GREY-TURNER's Sign: Gray-blue discoloration of the flanks, caused by pancreatic enzyme leakage to cutaneous tissue from the peritoneal cavity 9. Absent or decreased bowel sounds = paralytic ileus 10. ABD tenderness, rigidity, or guarding on palpation. Palpable mass may be found is pancreatic pseudocyst is found 11. Elevated temperature 12. Tachycardia 13. Decreased BP 14. Respiratory problems: left lung pleural effusions, atelectasis, pneumonia (check for adventitious/diminished breath sounds, dyspnea, orthopnea)

7. CULLEN's Sign: Gray-blue discoloration of the ABD and periumbilical area 8. GREY-TURNER's Sign: Gray-blue discoloration of the flanks, caused by pancreatic enzyme leakage to cutaneous tissue from the peritoneal cavity

Assessment of Acute Pancreatitis · History: 1. Conduct the interview after pain is controlled. Most patients have severe/constant ABD pain 2. Ask if ABD pain happens when drinking alcohol or eating a high-fat meal 3. Ask about alcohol consumption 4. Ask about family history of pancreatitis, trauma, biliary disease, alcoholism 5. Ask about past surgical procedures, cholecystectomy, or ERCPs 6. Ask about PUD, renal failure, vascular disorders, hyperparathyroidism, hyperlipidemia · Signs and Symptoms of Acute Pancreatitis: 1. Severe ABD pain in the MID-EPIGASTRIC AREA or LEFT UPPER QUADRANT 2. Pain has sudden onset and RADIATES TO THE BACK, LEFT FLANK, OR LEFT SHOULDER 3. Pain is intense, boring (feeling of going through body), and continuous and is worsened by lying in supine position. 4. Pain relief when lying in fetal position or by sitting upright and bending forward 5. Weight loss from nausea and vomiting 6. Generalized jaundice 7. CULLEN's Sign: ___________________________________________________________ 8. GREY-TURNER's Sign: ___________________________________________________________ 9. Absent or decreased bowel sounds = paralytic ileus 10. ABD tenderness, rigidity, or guarding on palpation. Palpable mass may be found is pancreatic pseudocyst is found 11. Elevated temperature 12. Tachycardia 13. Decreased BP 14. Respiratory problems: left lung pleural effusions, atelectasis, pneumonia (check for adventitious/diminished breath sounds, dyspnea, orthopnea) 15. MONITOR FOR CHANGES THAT INDICATE SHOCK: § Hypotension and Tachycardia can indicate hemorrhage or fluid volume shifting or toxic effects of ABD sepsis from enzyme damage § Observe for changes in behavior and LOC that may be related to alcohol withdrawal, hypoxia, or impending sepsis with shock. 16. Psych Assessment: ask about alcoholism

MID-EPIGASTRIC AREA or LEFT UPPER QUADRANT

Assessment of Acute Pancreatitis · History: 1. Conduct the interview after pain is controlled. Most patients have severe/constant ABD pain 2. Ask if ABD pain happens when drinking alcohol or eating a high-fat meal 3. Ask about alcohol consumption 4. Ask about family history of pancreatitis, trauma, biliary disease, alcoholism 5. Ask about past surgical procedures, cholecystectomy, or ERCPs 6. Ask about PUD, renal failure, vascular disorders, hyperparathyroidism, hyperlipidemia · Signs and Symptoms of Acute Pancreatitis: 1. Severe ABD pain in the ____________________________________________________ 2. Pain has sudden onset and RADIATES TO THE BACK, LEFT FLANK, OR LEFT SHOULDER 3. Pain is intense, boring (feeling of going through body), and continuous and is worsened by lying in supine position. 4. Pain relief when lying in fetal position or by sitting upright and bending forward 5. Weight loss from nausea and vomiting 6. Generalized jaundice 7. CULLEN's Sign: Gray-blue discoloration of the ABD and periumbilical area 8. GREY-TURNER's Sign: Gray-blue discoloration of the flanks, caused by pancreatic enzyme leakage to cutaneous tissue from the peritoneal cavity 9. Absent or decreased bowel sounds = paralytic ileus 10. ABD tenderness, rigidity, or guarding on palpation. Palpable mass may be found is pancreatic pseudocyst is found 11. Elevated temperature 12. Tachycardia 13. Decreased BP 14. Respiratory problems: left lung pleural effusions, atelectasis, pneumonia (check for adventitious/diminished breath sounds, dyspnea, orthopnea) 15. MONITOR FOR CHANGES THAT INDICATE SHOCK: § Hypotension and Tachycardia can indicate hemorrhage or fluid volume shifting or toxic effects of ABD sepsis from enzyme damage § Observe for changes in behavior and LOC that may be related to alcohol withdrawal, hypoxia, or impending sepsis with shock. 16. Psych Assessment: ask about alcoholism

1. Episodic (gallbladder attacks) or vague upper ABD pain or discomfort that can radiate to the RIGHT SHOULDER/SCAPULA 2. Pain triggered by a high-fat or high-volume meal 3. Pain can be mild, persistent ache to a steady, constant in the RIGHT UPPER QUADRANT 4. Anorexia 5. Nausea, vomiting (can lead to dehydration) 6. Dyspepsia (indigestion) 7. Eructation (belching) 8. Flatulence (gas) 9. Feeling of ABD fullness 10. Rebound tenderness (Blumberg's Sign): physician pushes fingers deeply and steadily into the patient's ABD and then quickly releases the pressure. Pain that results from the rebound indicates peritoneal inflammation

Assessment of Cholecystitis · History: height, weight, vitals, food preferences (excessive fat and cholesterol, high in calories, low in fiber, high in refined white carbs); ask if certain foods cause pain § Ask if GI symptoms occur when fatty food is eaten: flatulence, dyspepsia (indigestion), eructation (belching), anorexia, nausea, vomiting, and abdominal pain/discomfort § Ask about sedentary lifestyle, rapid weight loss, prolonged fasting, pregnancy, hormone replacement therapy or oral contraceptives § Ask about family history of gallbladder disease · Signs and Symptoms of Cholecystitis: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. Sausage-shaped mass (distended gallbladder) on deep palpation 12. Worsening of ABD pain on percussion over posterior rib cage 13. Fever (with infectious process) 14. Biliary Colic: severe pain produced by obstruction of the cystic duct of the gallbladder or movement of one or more stones. (when stone is moving or lodged in the duct, it causes tissue spasms) § It can be so severe that it occurs with tachycardia, pallor, diaphoresis, and prostration (extreme exhaustion) § Assess for possible shock caused by biliary colic § Report to the doctor or call rapid response team if this occurs. STAY WITH PATIENT and keep the HOB FLAT. We use NSAIDs and/or OPIOIDS (watch BP/RR due to shock risk) 15. Chronic Cholecystitis: § Jaundice, clay colored stools, dark urine, steatorrhea (fatty stools), Pruritis § May have slowly developing symptoms 16. Older Adults & Diabetics have Atypical Symptoms § Absence of Pain & Fever § Just Localized Tenderness § Older adult may get confused (delirium) as the first symptom

severe pain produced by obstruction of the cystic duct of the gallbladder or movement of one or more stones. (when stone is moving or lodged in the duct, it causes tissue spasms) § It can be so severe that it occurs with tachycardia, pallor, diaphoresis, and prostration (extreme exhaustion) § Assess for possible shock caused by biliary colic § Report to the doctor or call rapid response team if this occurs. STAY WITH PATIENT and keep the HOB FLAT. We use NSAIDs and/or OPIOIDS (watch BP/RR due to shock risk)

Assessment of Cholecystitis · History: height, weight, vitals, food preferences (excessive fat and cholesterol, high in calories, low in fiber, high in refined white carbs); ask if certain foods cause pain § Ask if GI symptoms occur when fatty food is eaten: flatulence, dyspepsia (indigestion), eructation (belching), anorexia, nausea, vomiting, and abdominal pain/discomfort § Ask about sedentary lifestyle, rapid weight loss, prolonged fasting, pregnancy, hormone replacement therapy or oral contraceptives § Ask about family history of gallbladder disease · Signs and Symptoms of Cholecystitis: 1. Episodic (gallbladder attacks) or vague upper ABD pain or discomfort that can radiate to the RIGHT SHOULDER/SCAPULA 2. Pain triggered by a high-fat or high-volume meal 3. Pain can be mild, persistent ache to a steady, constant in the RIGHT UPPER QUADRANT 4. Anorexia 5. Nausea, vomiting (can lead to dehydration) 6. Dyspepsia (indigestion) 7. Eructation (belching) 8. Flatulence (gas) 9. Feeling of ABD fullness 10. Rebound tenderness (Blumberg's Sign): physician pushes fingers deeply and steadily into the patient's ABD and then quickly releases the pressure. Pain that results from the rebound indicates peritoneal inflammation 11. Sausage-shaped mass (distended gallbladder) on deep palpation 12. Worsening of ABD pain on percussion over posterior rib cage 13. Fever (with infectious process) 14. Biliary Colic: ______________________________________________________________________________________________ - - - 15. Chronic Cholecystitis: § Jaundice, clay colored stools, dark urine, steatorrhea (fatty stools), Pruritis § May have slowly developing symptoms 16. Older Adults & Diabetics have Atypical Symptoms § Absence of Pain & Fever § Just Localized Tenderness § Older adult may get confused (delirium) as the first symptom

§ Absence of Pain & Fever § Just Localized Tenderness § Older adult may get confused (delirium) as the first symptom

Assessment of Cholecystitis · History: height, weight, vitals, food preferences (excessive fat and cholesterol, high in calories, low in fiber, high in refined white carbs); ask if certain foods cause pain § Ask if GI symptoms occur when fatty food is eaten: flatulence, dyspepsia (indigestion), eructation (belching), anorexia, nausea, vomiting, and abdominal pain/discomfort § Ask about sedentary lifestyle, rapid weight loss, prolonged fasting, pregnancy, hormone replacement therapy or oral contraceptives § Ask about family history of gallbladder disease · Signs and Symptoms of Cholecystitis: 1. Episodic (gallbladder attacks) or vague upper ABD pain or discomfort that can radiate to the RIGHT SHOULDER/SCAPULA 2. Pain triggered by a high-fat or high-volume meal 3. Pain can be mild, persistent ache to a steady, constant in the RIGHT UPPER QUADRANT 4. Anorexia 5. Nausea, vomiting (can lead to dehydration) 6. Dyspepsia (indigestion) 7. Eructation (belching) 8. Flatulence (gas) 9. Feeling of ABD fullness 10. Rebound tenderness (Blumberg's Sign): physician pushes fingers deeply and steadily into the patient's ABD and then quickly releases the pressure. Pain that results from the rebound indicates peritoneal inflammation 11. Sausage-shaped mass (distended gallbladder) on deep palpation 12. Worsening of ABD pain on percussion over posterior rib cage 13. Fever (with infectious process) 14. Biliary Colic: severe pain produced by obstruction of the cystic duct of the gallbladder or movement of one or more stones. (when stone is moving or lodged in the duct, it causes tissue spasms) § It can be so severe that it occurs with tachycardia, pallor, diaphoresis, and prostration (extreme exhaustion) § Assess for possible shock caused by biliary colic § Report to the doctor or call rapid response team if this occurs. STAY WITH PATIENT and keep the HOB FLAT. We use NSAIDs and/or OPIOIDS (watch BP/RR due to shock risk) 15. Chronic Cholecystitis: § Jaundice, clay colored stools, dark urine, steatorrhea (fatty stools), Pruritis § May have slowly developing symptoms 16. Older Adults & Diabetics have Atypical Symptoms: - - -

continuous and burning/gnawing dullness with periods of acute exacerbations (flare ups). Pain is intense and relentless

Assessment of Chronic Pancreatitis 1. Intense ABD pain, that is _____________________________________________ 2. Abdominal tenderness 3. Ascites (produces dullness on ABD percussion) 4. Possible LEFT UPPER QUADRANT mass (is pseudocyst or abscess is present) 5. Respiratory compromise manifested by adventitious or diminished breath sounds, dyspnea, or orthopnea 6. Steatorrhea: clay-colored, foul smelling, fatty stools that increase in volume as pancreatic insufficiency progresses 7. Weight loss, muscle wasting 8. Jaundice 9. Dark urine 10. Polyuria, polydipsia, polyphagia (DM) 11. Labs: a. Elevated serum amylase and lipase b. Elevated serum bilirubin or alkaline phosphatase levels with obstruction of intrahepatic bile duct c. Intermittent elevations in serum glucose 12. Diagnostics: a. Endoscopic Retrograde Cholangiopancreatography (ERCP) to visualize pancreas and bile ducts b. CT scan, MRI, ABD ultrasound, endoscopic ultrasound (EUS)

1. Often develops in a slow and vague manner 2. Glucose intolerance 3. Splenomegaly, and enlarged liver or gallbladder (may be palpable) 4. Flatulence 5. Gastrointestinal bleeding from esophageal or gastric varices 6. Ascites (ABD fluid): ABD swelling and distention; percussion reveals dullness 7. Leg or calf pain with swelling or redness (DVT, VTE) 8. With advanced cancer, palpation shows a firm, fixed mass in the LEFT UPPER ABD QUADRANT or EPIGASTRIC REGION 9. Jaundice (often suggests late, advanced disease): this occurs b/c liver/gallbladder are involved; jaundice often worsens as tumor spreads a. Icterus: yellowing of the sclera and mucous membranes 10.Clay-colored stools 11.Dark urine 12.ABD pain: vague, dull, nonspecific that radiates into back (pain in late disease may be related to eating or activity); referred back pain may be caused by pressure on the nerve plexus 13.Weight loss 14.Anorexia accompanied by early satiety, n/v, as is common 15.Nausea/vomiting 16.Weakness and fatigue (low energy, need for rest, inability to do usual activities) 17. Skin: dry, stretch marks, pruritis (bile salt collection) 18. Possibly new diagnosis of diabetes

Assessment of Pancreatic Cancer · Signs and Symptoms of Pancreatic Cancer: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. · Laboratory and Diagnostic Findings: 1. Serum amylase and lipase; alkaline phosphatase; bilirubin are increased 2. Elevated carcinoembryonic antigen (CEA) levels 3. Tumor marker CA 19-9 is a serologic test for potential spread or recurrence 4. ABD ultrasound and CT confirm presence of tumor 5. Endoscopic Retrograde Cholangiopancreatography (ERCP) provides visual diagnostic data 6. Percutaneous transhepatic biliary cholangiogram (PTBD) with drain placement will decompress the blocked biliary system

1. Impaired Digestion 2. Inadequate Nutrition 3. Impaired Immunity Secondary to Inflammation

Biliary System · Biliary System is composed of the Liver, Gallbladder, & Pancreas (includes the ducts that connect between as well) · Biliary System is responsible for secreting enzymes to promote food digestion in the stomach and small intestine · Problems with Biliary System result in: 1. 2. 3. · Disorders of the gallbladder and pancreases may extend to other organs because of the close anatomic location of these organs, if the primary problem is not treated early. · Inflammation, which impairs immunity, is caused by obstruction in the biliary system from gallstones, edema, stricture, or tumors. § For example, gallstones in the cystic duct cause cholecystitis. Gallstones lodged in the ampulla of Vater block the flow of bile and pancreatic secretions, which can result in pancreatitis. Both can cause abdominal discomfort

metabolic imbalances of cholesterol and bile salts

Cholecystitis · Cholecystitis is an inflammation of the gallbladder that affects many adults, commonly in affluent countries. It can be chronic, although most patients have the acute type · Acute Cholecystitis: there are two types, calculous and acalculous. 1. Calculous Cholecystitis: chemical irritation and inflammation result from gallstones (Cholelithiasis) that obstruct the cystic duct, gallbladder neck, or common bile duct (choledocholithiasis) § When the gallbladder is inflamed, trapped bile is reabsorbed and acts as a chemical irritant to the gallbladder wall. Reabsorbed bile, alone with impaired circulation, edema, and distention of the gallbladder, causes ischemia and infarction. § The result is tissue sloughing with necrosis and gangrene within the gallbladder itself. The gallbladder wall may perforate (rupture), which can result in abscesses. § Peritonitis (peritoneum infection) can result if a perforation is large. § Abnormal metabolism of cholesterol and bile salts play a role in gallstone formation. The gallbladder provides a good environment for production of stones because it only occasionally mixes its normally abundant mucous with its highly viscous, concentrated bile. § Impaired gallbladder mobility can lead to stone formation by delaying bile emptying and causing biliary stasis. § Gallstones are composed of substances normally found in bile, such as cholesterol, bilirubin, bile salts, calcium, and various proteins. They are either cholesterol stones or pigment stones § Cholesterol stones form as a result of ____________________________________________________ § Bacteria can collect around the stones, which can lead to life-threatening suppurative cholangitis 2. Acalculous Cholecystitis (inflammation occurring without gallstones) is associated with biliary stasis caused by any condition that affects the regular filling or emptying of the gallbladder § Example: a decrease in blood flow to the gallbladder or anatomic problems like twisting or kinking of the gallbladder neck or cystic duct can result in pancreatic enzyme reflux into the gallbladder, causing inflammation § Sphincter of Oddi dysfunction (SOD) can occur to cause reflux and inflammation. Most cases of this type of Cholecystitis occur in patients with sepsis, severe trauma/burns, long-term parenteral nutrition, MODS, major surgery, or hypovolemia

sepsis, severe trauma/burns, long-term parenteral nutrition, MODS, major surgery, or hypovolemia

Cholecystitis · Cholecystitis is an inflammation of the gallbladder that affects many adults, commonly in affluent countries. It can be chronic, although most patients have the acute type · Acute Cholecystitis: there are two types, calculous and acalculous. 1. Calculous Cholecystitis: chemical irritation and inflammation result from gallstones (Cholelithiasis) that obstruct the cystic duct, gallbladder neck, or common bile duct (choledocholithiasis) § When the gallbladder is inflamed, trapped bile is reabsorbed and acts as a chemical irritant to the gallbladder wall. Reabsorbed bile, alone with impaired circulation, edema, and distention of the gallbladder, causes ischemia and infarction. § The result is tissue sloughing with necrosis and gangrene within the gallbladder itself. The gallbladder wall may perforate (rupture), which can result in abscesses. § Peritonitis (peritoneum infection) can result if a perforation is large. § Abnormal metabolism of cholesterol and bile salts play a role in gallstone formation. The gallbladder provides a good environment for production of stones because it only occasionally mixes its normally abundant mucous with its highly viscous, concentrated bile. § Impaired gallbladder mobility can lead to stone formation by delaying bile emptying and causing biliary stasis. § Gallstones are composed of substances normally found in bile, such as cholesterol, bilirubin, bile salts, calcium, and various proteins. They are either cholesterol stones or pigment stones § Cholesterol stones form as a result of metabolic imbalances of cholesterol and bile salts § Bacteria can collect around the stones, which can lead to life-threatening suppurative cholangitis 2. Acalculous Cholecystitis (inflammation occurring without gallstones) is associated with biliary stasis caused by any condition that affects the regular filling or emptying of the gallbladder § Example: a decrease in blood flow to the gallbladder or anatomic problems like twisting or kinking of the gallbladder neck or cystic duct can result in pancreatic enzyme reflux into the gallbladder, causing inflammation § Sphincter of Oddi dysfunction (SOD) can occur to cause reflux and inflammation. Most cases of this type of Cholecystitis occur in patients with __________________________________________________________

Inflammation of the liver's bile channels or bile ducts may cause intrahepatic obstructive jaundice, resulting in an increase in circulating levels of bilirubin (major pigment of bile)

Cholecystitis · Cholecystitis is an inflammation of the gallbladder that affects many adults, commonly in affluent countries. It can be chronic, although most patients have the acute type · Chronic Cholecystitis results when repeated episodes of cystic duct obstruction cause chronic inflammation. Calculi are almost always present. The gallbladder becomes fibrotic and contracted, which results in decreased motility and deficient absorption. § Pancreatitis and Cholangitis (bile duct inflammation) can occur as chronic complications of Cholecystitis. These result from the backup of bile throughout the biliary tract. Bile obstruction leads to JAUNDICE § Jaundice (yellow discoloration of the skin and mucous membranes) and Icterus (yellow discoloration of the sclera) can occur in most patients with acute cholecystitis but are most commonly seen with the chronic form. § Obstructed bile causes edema of the ducts or gallstones contribute to extrahepatic obstructive jaundice. Jaundice in cholecystitis may also be caused by direct liver involvement: ______________________________________________________________________________________________________________ § In the adult with obstructive jaundice, normal bile flow through the duodenum is blocked, and excessive bile salts accumulate in the skin, leading to pruritis (itching) or a bruising sensation. Urobilirubin accounts for the normal color of feces, so when urobilirubin formation is stopped, clay colored stools result. § When an excess of circulating bilirubin occurs, the urine becomes dark and foamy (kidneys trying to clear bilirubin)

ALCOHOLISM

Chronic Pancreatitis · Chronic Pancreatitis is a progressive, destructive disease of the pancreas that has remissions and exacerbations (flare ups). Inflammation and fibrosis of the tissue contribute to pancreatic insufficiency and diminished function of the organ. § _____________________ is the primary risk factor for chronic calcifying pancreatitis (CCP). In early stages of this disease, pancreatic secretions precipitate insoluble proteins that clog pancreatic ducts and flow of pancreatic juices. The cellular lining of ducts ulcerate, and this inflammation causes fibrosis of the pancreatic tissue. · Intraductal calcification and marked pancreatic tissue destruction (necrosis) develop in late stages. The organ becomes hard and firm due to cell atrophy and pancreatic insufficiency. § Chronic Obstructive Pancreatitis develops from inflammation, spasms, and obstruction of the sphincter of Oddi (often from gallstones). Inflammation and sclerotic lesions occur in the head of the pancreas and around the ducts, causing obstruction and backflow of pancreatic secretions. § Autoimmune Pancreatitis is a chronic inflammatory process in which immunoglobulins invade pancreas. This disease does have a risk for pancreatic cancer § Idiopathic and hereditary chronic pancreatitis may be associated with the SPINK1 and CFTR gene mutation and with mutations in the BRCA2 gene. This disease has a 53-fold increased risk of pancreatic cancer. · Pancreatic insufficiency in any type of chronic pancreatitis causes loss of exocrine function. Most patients have decrease pancreatic secretions and bicarbonate. · Pancreatic enzyme secretion must be greatly reduced to produce steatorrhea (resulting from severe malabsorption of fats). These stools are pale, bulky, and frothy, and have an offensive odor. The action of colonic bacteria on unabsorbed lipids/proteins causes foul odor. On inspection of the stool, fat content is visible (may lose up to 40g of fat a day) · Fat malabsorption contributes to weight loss and muscle wasting and leads to general debilitation. Protein malabsorption results in "starvation" edema of the feet, legs, and hands caused by decreased levels of albumin · Loss of pancreatic endocrine function is responsible for development of diabetes mellitus · Patients with chronic pancreatitis may have pulmonary complications, such as pleuritic pain, pleural effusions, and pulmonary infiltrates. Pancreatic ascites may decrease diaphragmatic excursion and lung expansion, increasing risk of ARDS

DRINKING to prevent during pain attacks and extension of inflammation and pancreatic insufficiency. If alcohol is consumed, the pain will return and further autodigestion of the pancreas may lead to chronic pancreatitis.

Home Care Coordination and Transition Management for Acute Pancreatitis 1. Some patients may be very weakened and need to remain on one floor of the home, limit stair climbing/strenuous activities until strength is regained 2. Education needs to be started early in the hospitalization period, as son as the acute episodes of pain have subsided. 3. ABSTAIN FROM ___________________________________________ 4. Report: acute ABD pain, biliary tract disease (jaundice, clay-colored stools, darkened urine) occurs (indicates complications/disease progression) 5. May need visits from home health nurse for wound care and assistance with ADLs 6. Referral to AA for alcoholism.

1. fatty, fried, and "fast" food 2. dairy products, chocolate, nuts, gravies 3. gas-forming foods: beans, cabbage, cauliflower, broccoli

Home Care Coordination and Transition Management for Cholecystitis · Nutritional intervention: avoid fatty, fried, and "fast" food and report any signs and postoperative complications to the provider · Foods to avoid: 1. 2. 3.

home care nurse, palliation, or hospice care and cancer support groups

Home Care Coordination and Transition Management for Pancreatic Cancer 1. Collab with case management for discharge needs. 2. Patient and family need compassionate support to deal with issues related to the illness 3. The diagnosis of pancreatic cancer can be frightening and overwhelming 4. Refer patients to mental health support resources as indicated 5. In many cases, the diagnosis of pancreatic cancer is made just months before death occurs. The patient needs time to adjust to diagnosis, which is usually made too late for cure or prolonged survival. 6. Refer to ________________________________________________________

the return of peristalsis by asking the patient if they have passed flatus or stool (most reliable). The return of bowel sounds is not the most reliable indicators of return of peristalsis.

Managing Acute Pain for Acute Pancreatitis (Non-Surgical Interventions) · Priorities for patient care are to provide supportive care by relieving symptoms, decreasing inflammation or treating complications. · ABCs!!! Collab with RT as needed. Monitor respiratory status every 4-8hr of more PRN and provide O2 to promote comfort in breathing. Watch for s/s of respiratory failure!!! 1. Respiratory complications, such as pleural effusions increase discomfort. 2. Fluid Overload is detected by assessing for weight gain, crackles, and dyspnea · ABD pain is the most common symptom of pancreatitis. Nursing interventions are aimed at controlling pain by decreasing GI tract activity, thus decreasing pancreatic stimulation · MILD pancreatitis requires hydration with IV fluids, pain control, and drug therapy · If patient has a life-threatening complications, or requires frequent monitoring they are sent to ICU for invasive hemodynamic monitoring · FASTING AND REST: To rest the pancreas and reduce pancreatic enzyme secretion, withhold food and fluids (NPO) during the acute period. IV isotonic fluids (and possible calcium/magnesium replacement) will be given to maintain hydration. 1. NG drainage and suction are reserved for more severely ill patients who have continuous vomiting or biliary obstruction. Gastric Decompression prevents gastric juices from flowing into the duodenum 2. Because paralytic ileus is a common complication of acute pancreatitis, prolonged nasogastric intubation may be needed. Assess frequently for _______________________________________________________________________________________ 3. When patient is NPO or has an NG tube, remind UAP to implement frequent oral and nares hygiene measures to keep mucous membranes moist and free of inflammation/crusting. 4. Because of the drying effect of drugs and the absence of oral hydration, the mouth can get very dry, cause discomfort, and result in parotitis (inflammation of the parotid [salivary] glands) · To decrease pain, opioids are commonly used via PCA. 1. Morphine or hydromorphone are used because meperidine can cause seizures (especially older adults). 2. IV or transdermal fentanyl and epidural analgesia may be used 3. In MILD pancreatitis, the pain usually subsides in 2-3 days. 4. In SEVERE pancreatitis, the ABD pain and tenderness may persist up to 2 weeks · Histamine Receptor antagonists (ranitidine) and Proton pump inhibitors (omeprazole) help decrease gastric acid secretion · Antibiotics are indicated primarily for those with necrotizing pancreatitis. · Help the patient assume a side-lying position (with legs drawn to chest) to decrease ABD pain of pancreatitis ("fetal position"). Sitting with the knees flexed is also helpful · Monitor for hypocalcemia: Chvostek's and Trousseau's sign, which both cause spasms after stimulating associated nerves · Lowering anxiety level can help reduce pain. Provide reassurance, diversional activities, music, reading materials, and encourage visitors to direct attention away from pain · If pancreatitis was caused by gallstones, an ERCP with a sphincterotomy (opening of the sphincter of Oddi) may be done. · Laparoscopic cholecystectomy may be done if ERCP is not successful in removing gallstones

side-lying position (with legs drawn to chest) to decrease ABD pain of pancreatitis ("fetal position"). Sitting with the knees flexed is also helpful

Managing Acute Pain for Acute Pancreatitis (Non-Surgical Interventions) · Priorities for patient care are to provide supportive care by relieving symptoms, decreasing inflammation or treating complications. · ABCs!!! Collab with RT as needed. Monitor respiratory status every 4-8hr of more PRN and provide O2 to promote comfort in breathing. Watch for s/s of respiratory failure!!! 1. Respiratory complications, such as pleural effusions increase discomfort. 2. Fluid Overload is detected by assessing for weight gain, crackles, and dyspnea · ABD pain is the most common symptom of pancreatitis. Nursing interventions are aimed at controlling pain by decreasing GI tract activity, thus decreasing pancreatic stimulation · MILD pancreatitis requires hydration with IV fluids, pain control, and drug therapy · If patient has a life-threatening complications, or requires frequent monitoring they are sent to ICU for invasive hemodynamic monitoring · FASTING AND REST: To rest the pancreas and reduce pancreatic enzyme secretion, withhold food and fluids (NPO) during the acute period. IV isotonic fluids (and possible calcium/magnesium replacement) will be given to maintain hydration. 1. NG drainage and suction are reserved for more severely ill patients who have continuous vomiting or biliary obstruction. Gastric Decompression prevents gastric juices from flowing into the duodenum 2. Because paralytic ileus is a common complication of acute pancreatitis, prolonged nasogastric intubation may be needed. Assess frequently for the return of peristalsis by asking the patient if they have passed flatus or stool (most reliable). The return of bowel sounds is not the most reliable indicators of return of peristalsis. 3. When patient is NPO or has an NG tube, remind UAP to implement frequent oral and nares hygiene measures to keep mucous membranes moist and free of inflammation/crusting. 4. Because of the drying effect of drugs and the absence of oral hydration, the mouth can get very dry, cause discomfort, and result in parotitis (inflammation of the parotid [salivary] glands) · To decrease pain, opioids are commonly used via PCA. 1. Morphine or hydromorphone are used because meperidine can cause seizures (especially older adults). 2. IV or transdermal fentanyl and epidural analgesia may be used 3. In MILD pancreatitis, the pain usually subsides in 2-3 days. 4. In SEVERE pancreatitis, the ABD pain and tenderness may persist up to 2 weeks · Histamine Receptor antagonists (ranitidine) and Proton pump inhibitors (omeprazole) help decrease gastric acid secretion · Antibiotics are indicated primarily for those with necrotizing pancreatitis. · Help the patient assume a ________________________________________________________________________________ · Monitor for hypocalcemia: Chvostek's and Trousseau's sign, which both cause spasms after stimulating associated nerves · Lowering anxiety level can help reduce pain. Provide reassurance, diversional activities, music, reading materials, and encourage visitors to direct attention away from pain · If pancreatitis was caused by gallstones, an ERCP with a sphincterotomy (opening of the sphincter of Oddi) may be done. · Laparoscopic cholecystectomy may be done if ERCP is not successful in removing gallstones

Collab with RT as needed. Monitor respiratory status every 4-8hr of more PRN and provide O2 to promote comfort in breathing. Watch for s/s of respiratory failure!!! 1. Respiratory complications, such as pleural effusions increase discomfort. 2. Fluid Overload is detected by assessing for weight gain, crackles, and dyspnea

Managing Acute Pain for Acute Pancreatitis (Non-Surgical Interventions) · Priorities for patient care are to provide supportive care by relieving symptoms, decreasing inflammation or treating complications. · ABCs!!! ________________________________________________________________________________________________ · ABD pain is the most common symptom of pancreatitis. Nursing interventions are aimed at controlling pain by decreasing GI tract activity, thus decreasing pancreatic stimulation · MILD pancreatitis requires hydration with IV fluids, pain control, and drug therapy · If patient has a life-threatening complications, or requires frequent monitoring they are sent to ICU for invasive hemodynamic monitoring · FASTING AND REST: To rest the pancreas and reduce pancreatic enzyme secretion, withhold food and fluids (NPO) during the acute period. IV isotonic fluids (and possible calcium/magnesium replacement) will be given to maintain hydration. 1. NG drainage and suction are reserved for more severely ill patients who have continuous vomiting or biliary obstruction. Gastric Decompression prevents gastric juices from flowing into the duodenum 2. Because paralytic ileus is a common complication of acute pancreatitis, prolonged nasogastric intubation may be needed. Assess frequently for the return of peristalsis by asking the patient if they have passed flatus or stool (most reliable). The return of bowel sounds is not the most reliable indicators of return of peristalsis. 3. When patient is NPO or has an NG tube, remind UAP to implement frequent oral and nares hygiene measures to keep mucous membranes moist and free of inflammation/crusting. 4. Because of the drying effect of drugs and the absence of oral hydration, the mouth can get very dry, cause discomfort, and result in parotitis (inflammation of the parotid [salivary] glands) · To decrease pain, opioids are commonly used via PCA. 1. Morphine or hydromorphone are used because meperidine can cause seizures (especially older adults). 2. IV or transdermal fentanyl and epidural analgesia may be used 3. In MILD pancreatitis, the pain usually subsides in 2-3 days. 4. In SEVERE pancreatitis, the ABD pain and tenderness may persist up to 2 weeks · Histamine Receptor antagonists (ranitidine) and Proton pump inhibitors (omeprazole) help decrease gastric acid secretion · Antibiotics are indicated primarily for those with necrotizing pancreatitis. · Help the patient assume a side-lying position (with legs drawn to chest) to decrease ABD pain of pancreatitis ("fetal position"). Sitting with the knees flexed is also helpful · Monitor for hypocalcemia: Chvostek's and Trousseau's sign, which both cause spasms after stimulating associated nerves · Lowering anxiety level can help reduce pain. Provide reassurance, diversional activities, music, reading materials, and encourage visitors to direct attention away from pain · If pancreatitis was caused by gallstones, an ERCP with a sphincterotomy (opening of the sphincter of Oddi) may be done. · Laparoscopic cholecystectomy may be done if ERCP is not successful in removing gallstones

Biliary Stents

Nursing Interventions and Treatment for Pancreatic Cancer · Chemotherapy and radiation to relive pain by shrinking the tumor. It can be done before or after surgery · Chemotherapy has had limited success in increasing survival time. Therefore, combining agents has been more successful than single-agent chemo · Targeted therapies with growth factor inhibitors, anti-angiogenesis factors, and kinase inhibitors focus on cancer cells with little/no effect on healthy cells. · Analgesics: high-dose opioids (usually morphine); because of the poor prognosis, drug dependency is not a consideration · Intensive external beam radiation may offer pain relief by shrinking tumor cells, but does not improve survival rates. · _________________are placed percutaneously for those experiencing biliary obstruction and pain. Surgical Management of Pancreatic Cancer · Complete surgical resection of the pancreatic tumor offers the patient the only effective treatment, but it is done only in patients with small tumors. · Partial Pancreatectomy is the preferred surgery for tumors smaller than 3cm in diameter · Minimally invasive surgery (MIS) help with staging, palliation, and removal of pancreatic cancers · For larger tumors, the surgeon may do a radical pancreatectomy or the Whipple Procedure (pancreaticoduodenectomy). These have been done with the open approach, but laparoscopic procedures are becoming more popular as surgeons learn the new technique

1. Pancrelipase is usually prescribed in a capsule or tablet 2. DO NOT CHEW OR CRUSH Pancrelipase delayed release tablets or enteric tablets 3. Take medications with all meals and snacks and follow with a glass of water 4. Administer enzymes after antacid or H2 blockers (decreased pH inactivates the drug) 5. Swallow the tablets or capsules without chewing to minimize oral irritation and allow the drug to be released slowly 6. If you cannot swallow the capsule, pierce the gelatin casing and place contents in applesauce (per textbook) 7. Do not mix enzyme preparations with protein-containing foods 8. Wipe lips after taking enzymes to avoid skin irritation 9. Follow up on all scheduled laboratory testing (pancrelipase can cause an increase in uric acid levels)

Nursing Interventions and Treatments for Chronic Pancreatitis · Focuses of patient care induce managing pain, assisting in maintaining nutrition, and preventing recurrence. Protein and Fat malabsorption result in significant weight loss and decreased muscle mass, so many nutrition interventions are the same as for acute pancreatitis · Medicate patients as prescribed to manage pain adequately. Opioid is used most frequently, but dependency may occur · Pancreatic Enzyme Replacement (PERT) is the standard of care to prevent malnutrition, malabsorption, and excessive weight loss 1. 2. 3. 4. 5. 6. 7. 8. 9. · If the patient has diabetes, insulin or oral antidiabetic agents are prescribed. We prefer tube feedings, but they may need TPN if extended bowel rest/NPO is required. Patients maintained on TPN are particularly susceptible to elevated glucose levels and require regular insulin additives to the solution. o Monitor glucose to control hyperglycemia. Check fingerstick glucose every 2-4 hours · Provide may prescribe drugs to decrease gastric acidity because gastric acidity destroys the lipase needed to break down fats. H2 blockers or PPIs neutralize stomach acid with oral sodium bicarbonate to enhance effectiveness of PERT · Patients often limit food intake to avoid increased pain, so nutritional maintenance is often difficult to achieve. Patients receive either TPN or TEN. · Collab with dietician for long-term management. They need an increased number of calories, sometimes up to 4,000-6,000 calories/day to maintain weight. 1. Food high in carbohydrates and protein help the healing process. 2. Foods high in fat are AVOIDED because it increases diarrhea 3. Alcohol is avoided

glucose to control hyperglycemia. Check fingerstick glucose every 2-4 hours

Nursing Interventions and Treatments for Chronic Pancreatitis · Focuses of patient care induce managing pain, assisting in maintaining nutrition, and preventing recurrence. Protein and Fat malabsorption result in significant weight loss and decreased muscle mass, so many nutrition interventions are the same as for acute pancreatitis · Medicate patients as prescribed to manage pain adequately. Opioid is used most frequently, but dependency may occur · Pancreatic Enzyme Replacement (PERT) is the standard of care to prevent malnutrition, malabsorption, and excessive weight loss 1. Pancrelipase is usually prescribed in a capsule or tablet 2. DO NOT CHEW OR CRUSH Pancrelipase delayed release tablets or enteric tablets 3. Take medications with all meals and snacks and follow with a glass of water 4. Administer enzymes after antacid or H2 blockers (decreased pH inactivates the drug) 5. Swallow the tablets or capsules without chewing to minimize oral irritation and allow the drug to be released slowly 6. If you cannot swallow the capsule, pierce the gelatin casing and place contents in applesauce (per textbook) 7. Do not mix enzyme preparations with protein-containing foods 8. Wipe lips after taking enzymes to avoid skin irritation 9. Follow up on all scheduled laboratory testing (pancrelipase can cause an increase in uric acid levels) · If the patient has diabetes, insulin or oral antidiabetic agents are prescribed. We prefer tube feedings, but they may need TPN if extended bowel rest/NPO is required. Patients maintained on TPN are particularly susceptible to elevated glucose levels and require regular insulin additives to the solution. § Monitor ________________ · Provide may prescribe drugs to decrease gastric acidity because gastric acidity destroys the lipase needed to break down fats. H2 blockers or PPIs neutralize stomach acid with oral sodium bicarbonate to enhance effectiveness of PERT · Patients often limit food intake to avoid increased pain, so nutritional maintenance is often difficult to achieve. Patients receive either TPN or TEN. · Collab with dietician for long-term management. They need an increased number of calories, sometimes up to 4,000-6,000 calories/day to maintain weight. 1. Food high in carbohydrates and protein help the healing process. 2. Foods high in fat are AVOIDED because it increases diarrhea 3. Alcohol is avoided

1. The patient lies flat on a water-filled pad and shock waves break up the large stones into smaller ones that can be passed through the digestive system 2. During procedure, the patient may have some discomfort from movement of stones or gallbladder spasms 3. Ursodeoxycholic Acid (UDCA), a therapeutic bile acid, may be given after the procedure to help dissolve the remaining stone fragments

Nursing Interventions for Cholecystitis Managing Acute Pain (Non-Surgically) for Cholecystitis · Provide supportive care by relieving symptoms, increasing comfort, and decreasing inflammation · Acute pain is present when gallstones partially/totally obstruct the cystic or common bile duct. Most find that they need to avoid fatty foods to prevent further episodes of biliary colic. Withhold foods if nausea/vomiting occur. IV therapy is used for hydration · Drug Therapy: Acute biliary pain requires OPIOID ANALGESIA, such as Morphine or Hydromorphone (so WATCH BP & RR because biliary pain can cause SHOCK!). All Opioids may cause some degree of Sphincter of Oddi Spasm. § Ketorolac, an NSAID, may be used for mild-moderate alterations in comfort. Monitor for s/s of GI distress and pain because this drug can cause GI bleeding. § Antiemetics for nausea and vomiting § IV antibiotics depending on cause or as a one-time dose for surgery § Oral Bile Acid Dissolution or Gallstone stabilizing Agents 1. Ursodiol and chenodiol may be given as long term therapy to dissolve/stabilize gallstones 2. Caution use in patients with liver disease or varices 3. A gallbladder ultrasound is required every 6 months for the first year of therapy to determine effectiveness 4. Report diarrhea, vomiting, or severe ABD pain (especially if it radiates to the shoulders) 5. Take the medication with food and milk · Extracorporeal Shock Wave Lithotripsy (ESWL) is a procedure to break up gallstones. This can only be used for patients who's stones are small enough (usually less than 3cm), who have a normal weight, cholesterol-based stones, and good gallbladder function: 1. 2. 3. · Insertion of a Percutaneous Transhepatic Biliary Catheter (drain) using CT or ultrasound guidance to open the blocked bile ducts so bile can flow (cholecystostomy). This may be done if the patient does not qualify for cholecystectomy. 1. Catheters can be placed several ways, depending on condition of the bile ducts, as an internal, external, or internal/external drain. 2. They usually divert bile from the liver into the duodenum to bypass a stricture 3. When all of the bile enters the duodenum, it is an internal drain. When some empties into the duodenum and some into a bag, it is internal/external drain a. If jaundice or leakage around the catheter site occurs, teach the patient to reconnect the catheter to the drainage bag and have a follow-up cholangiogram injection. 4. An external only catheter is connected temporarily or permanently to a drainage bag.

1. Ursodiol and chenodiol may be given as long term therapy to dissolve/stabilize gallstones 2. Caution use in patients with liver disease or varices 3. A gallbladder ultrasound is required every 6 months for the first year of therapy to determine effectiveness 4. Report diarrhea, vomiting, or severe ABD pain (especially if it radiates to the shoulders) 5. Take the medication with food and milk

Nursing Interventions for Cholecystitis Managing Acute Pain (Non-Surgically) for Cholecystitis · Provide supportive care by relieving symptoms, increasing comfort, and decreasing inflammation · Acute pain is present when gallstones partially/totally obstruct the cystic or common bile duct. Most find that they need to avoid fatty foods to prevent further episodes of biliary colic. Withhold foods if nausea/vomiting occur. IV therapy is used for hydration · Drug Therapy: Acute biliary pain requires OPIOID ANALGESIA, such as Morphine or Hydromorphone (so WATCH BP & RR because biliary pain can cause SHOCK!). All Opioids may cause some degree of Sphincter of Oddi Spasm. § Ketorolac, an NSAID, may be used for mild-moderate alterations in comfort. Monitor for s/s of GI distress and pain because this drug can cause GI bleeding. § Antiemetics for nausea and vomiting § IV antibiotics depending on cause or as a one-time dose for surgery § Oral Bile Acid Dissolution or Gallstone stabilizing Agents: 1. 2. 3. 4. 5. · Extracorporeal Shock Wave Lithotripsy (ESWL) is a procedure to break up gallstones. This can only be used for patients who's stones are small enough (usually less than 3cm), who have a normal weight, cholesterol-based stones, and good gallbladder function 1. The patient lies flat on a water-filled pad and shock waves break up the large stones into smaller ones that can be passed through the digestive system 2. During procedure, the patient may have some discomfort from movement of stones or gallbladder spasms 3. Ursodeoxycholic Acid (UDCA), a therapeutic bile acid, may be given after the procedure to help dissolve the remaining stone fragments · Insertion of a Percutaneous Transhepatic Biliary Catheter (drain) using CT or ultrasound guidance to open the blocked bile ducts so bile can flow (cholecystostomy). This may be done if the patient does not qualify for cholecystectomy. 1. Catheters can be placed several ways, depending on condition of the bile ducts, as an internal, external, or internal/external drain. 2. They usually divert bile from the liver into the duodenum to bypass a stricture 3. When all of the bile enters the duodenum, it is an internal drain. When some empties into the duodenum and some into a bag, it is internal/external drain a. If jaundice or leakage around the catheter site occurs, teach the patient to reconnect the catheter to the drainage bag and have a follow-up cholangiogram injection. 4. An external only catheter is connected temporarily or permanently to a drainage bag.

Acute biliary pain requires OPIOID ANALGESIA, such as Morphine or Hydromorphone (so WATCH BP & RR because biliary pain can cause SHOCK!). All Opioids may cause some degree of Sphincter of Oddi Spasm.

Nursing Interventions for Cholecystitis Managing Acute Pain (Non-Surgically) for Cholecystitis · Provide supportive care by relieving symptoms, increasing comfort, and decreasing inflammation · Acute pain is present when gallstones partially/totally obstruct the cystic or common bile duct. Most find that they need to avoid fatty foods to prevent further episodes of biliary colic. Withhold foods if nausea/vomiting occur. IV therapy is used for hydration · Drug Therapy: _____________________________________________________________________________________________________ § Ketorolac, an NSAID, may be used for mild-moderate alterations in comfort. Monitor for s/s of GI distress and pain because this drug can cause GI bleeding. § Antiemetics for nausea and vomiting § IV antibiotics depending on cause or as a one-time dose for surgery § Oral Bile Acid Dissolution or Gallstone stabilizing Agents 1. Ursodiol and chenodiol may be given as long term therapy to dissolve/stabilize gallstones 2. Caution use in patients with liver disease or varices 3. A gallbladder ultrasound is required every 6 months for the first year of therapy to determine effectiveness 4. Report diarrhea, vomiting, or severe ABD pain (especially if it radiates to the shoulders) 5. Take the medication with food and milk · Extracorporeal Shock Wave Lithotripsy (ESWL) is a procedure to break up gallstones. This can only be used for patients who's stones are small enough (usually less than 3cm), who have a normal weight, cholesterol-based stones, and good gallbladder function 1. The patient lies flat on a water-filled pad and shock waves break up the large stones into smaller ones that can be passed through the digestive system 2. During procedure, the patient may have some discomfort from movement of stones or gallbladder spasms 3. Ursodeoxycholic Acid (UDCA), a therapeutic bile acid, may be given after the procedure to help dissolve the remaining stone fragments · Insertion of a Percutaneous Transhepatic Biliary Catheter (drain) using CT or ultrasound guidance to open the blocked bile ducts so bile can flow (cholecystostomy). This may be done if the patient does not qualify for cholecystectomy. 1. Catheters can be placed several ways, depending on condition of the bile ducts, as an internal, external, or internal/external drain. 2. They usually divert bile from the liver into the duodenum to bypass a stricture 3. When all of the bile enters the duodenum, it is an internal drain. When some empties into the duodenum and some into a bag, it is internal/external drain a. If jaundice or leakage around the catheter site occurs, teach the patient to reconnect the catheter to the drainage bag and have a follow-up cholangiogram injection. 4. An external only catheter is connected temporarily or permanently to a drainage bag.

1. Use ice and oral opioids for incision pain, if needed, for a few days. 2. For ABD or thoracic discomfort, heat application may be helpful 3. Bathe or shower the day after surgery 4. Patient can return to usual activities after 24 hours of rest; most can resume normal activities within a week 5. Some are able to return to usual diet after surgery, but others still have to carefully monitor diet to avoid high-fat foods because it will cause DIARRHEA INSTANTLY. 6. A large intake of fatty foods may result in ABD pain and diarrhea, which could result in a mild post-cholecystectomy syndrome (PCS). Introduce fatty foods ONE AT A TIME to see which ones are best tolerated

Nursing Interventions for Cholecystitis Nursing Interventions for Cholecystitis Surgical Management of Acute Pain for Cholecystitis: Cholecystectomy · Cholecystectomy is the surgical removal of the gallbladder. It can be done laparoscopically or in a traditional/open approach. · Laparoscopic Cholecystectomy (Lap Chole): a minimally invasive surgery (MIS), it is the gold standard and is done way more often than open surgery for gallbladder removal. - Postoperative Care MIS/Lap Chole: 1. After a Laparoscopic Cholecystectomy, assess the patient's O2 sat level frequently until the effects of anesthesia wear off. 2. Remind the patient to deep-breath every hour 3. Some patients have mild-severe discomfort with CO2 insufflation from CO2 retention in the ABD, which can be felt in the thorax and shoulders 4. Offer food and water when fully awake, monitor for n/v 5. Give ANTIEMETICS for n/v, such as ondansetron hydrochloride (Zofran) IV push 6. Maintain an IV line to administer fluids for HYDRATION until n/v subsides 7. Have HOB elevated to prevent aspiration from vomiting. 8. After nausea subsides, assist the patient to the bathroom to void. 9. Early ambulation promotes absorption of CO2, which can decrease post-op discomfort. 10. Give IV/oral opioid as needed after surgery. Continuous IV pain control is usually not required because there is only one or a few incisions (per textbook, but Cortese said these dudes need real good pain control cause it hurts). 11. The glue or Steri-Strips on surgical wounds fall off in about 10 days as wound heals 12. Patient is discharged often the same day, but older or obese patients may stay overnight. § Provide postop teaching about pain management, incision care, or follow-up appointments: 1. 2. 3. 4. 5. 6.

5. Give ANTIEMETICS for n/v, such as ondansetron hydrochloride (Zofran) IV push 6. Maintain an IV line to administer fluids for HYDRATION until n/v subsides 7. Have HOB elevated to prevent aspiration from vomiting. 8. After nausea subsides, assist the patient to the bathroom to void.

Nursing Interventions for Cholecystitis Surgical Management of Acute Pain for Cholecystitis: Cholecystectomy · Cholecystectomy is the surgical removal of the gallbladder. It can be done laparoscopically or in a traditional/open approach. · Laparoscopic Cholecystectomy (Lap Chole): a minimally invasive surgery (MIS), it is the gold standard and is done way more often than open surgery for gallbladder removal. - Postoperative Care MIS/Lap Chole: 1. After a Laparoscopic Cholecystectomy, assess the patient's O2 sat level frequently until the effects of anesthesia wear off. 2. Remind the patient to deep-breath every hour 3. Some patients have mild-severe discomfort with CO2 insufflation from CO2 retention in the ABD, which can be felt in the thorax and shoulders 4. Offer food and water when fully awake, monitor for n/v 5. 6. 7. 8. 9. Early ambulation promotes absorption of CO2, which can decrease post-op discomfort. 10. Give IV/oral opioid as needed after surgery. Continuous IV pain control is usually not required because there is only one or a few incisions (per textbook, but Cortese said these dudes need real good pain control cause it hurts). 11. The glue or Steri-Strips on surgical wounds fall off in about 10 days as wound heals 12. Patient is discharged often the same day, but older or obese patients may stay overnight. § Provide postop teaching about pain management, incision care, or follow-up appointments: 1. Use ice and oral opioids for incision pain, if needed, for a few days. 2. For ABD or thoracic discomfort, heat application may be helpful 3. Bathe or shower the day after surgery 4. Patient can return to usual activities after 24 hours of rest; most can resume normal activities within a week 5. Some are able to return to usual diet after surgery, but others still have to carefully monitor diet to avoid high-fat foods because it will cause DIARRHEA INSTANTLY. 6. A large intake of fatty foods may result in ABD pain and diarrhea, which could result in a mild post-cholecystectomy syndrome (PCS). Introduce fatty foods ONE AT A TIME to see which ones are best tolerated

1. The surgeon explains procedure and the nurse answers questions and reinforces teaching 2. Reinforce what to expect after surgery and review pain management, deep breathing exercises, incisional care, and leg exercises to prevent DVT 3. Routine prep for anesthesia and surgery

high infiber and low in fat

Nursing Interventions for Cholecystitis · Priority problems for patients with Cholecystitis: 1. Weight loss due to decreased intake because of pain, nausea, and inflammation 2. Acute pain due to cholecystitis Promoting Nutrition for Patients with Cholecystitis · Patients may decline food because of the ABD discomfort, nausea, and anorexia. · Collab with dietician to structure a nutrition plan. The patient's diet should be _____________________________________________ · Gas-producing foods should be AVOIDED · Small frequent meals are often preferable to standard meals daily · Ask about food preferences because foods they like are better tolerated than random foods provided · Weight regularly to assess for weight stabilization or concerns with weight loss. · Monitor Labs: BUN, prealbumin, albumin, total protein and transferrin

1. Report an absence of drainage with manifestations of nausea/pain (indicates obstruction) 2. Monitor for infection or bile leakage around skin 3. If prescribed, elevate the T-tube above the level of the ABD to prevent the total loss of bile 4. Clamp the tube 1 hr before and after meals to provide bile needed for food digestion 5. Stools are clay colored until biliary flow is established, so monitor stools 6. Monitor for bile peritonitis (pain, fever, jaundice) 7. Expect removal in 1-3 weeks.

Nursing Interventions for Cholecystitis · Traditional Open Cholecystectomy: use of this procedure has greatly declined. Patients who have this type of procedure usually have severe biliary obstruction, and the ducts are explored to ensure patency § The surgical nurse provides usually preoperative care and teaching on the same day of surgery § The surgeon removes the gallbladder through an incision and explores the biliary ducts for the presence of stones or obstruction § Surgeon usually inserts a drainage tube (Jackson-Pratt Drain) in the gallbladder to prevent fluid accumulation. · The drainage is usually SEROSANGUINEOUS (serous fluid mixed with blood) and is stained with bile in the first 24hr after surgery · Surgeon typically removes the drain within 24hours after surgery § Care of the T-tube for drainage of bile duct: 1. 2. 3. 4. 5. 6. 7. § Postoperative care is similar to that of ABD surgery under general anesthesia § Postop incision pain is controlled with Opioids using a PCA pain § Encourage patient to use coughing and deep-breathing exercises when pain is controlled and the incision is splinted § Antiemetics may be needed for post-op nausea and vomiting. Give them EARLY to prevent retching associated with vomiting and to decrease pain related to muscle straining § Patient is NPO until fully awake. § Document LOC, vitals, pain level, check incision for infection (redness, purulent drainage) § Resume activity gradually, and avoid heavy lifting for 4-6 weeks. Take showers instead of baths until drains are removed § Advance diet from clear liquids to solid foods as peristalsis returns to promote nutrition. Usually the patient resumes normal diet and is discharged to home 1-2 days after surgery § In the early post-op period, if bile flow is still reduced, a low-fat diet may reduce discomfort and prevent nausea. For most, no special diet is required § Eat Nutritious Foods! AVOID excessive intake of fatty foods, especially fried food, butter, and "fast food". If obese, recommend a weight-reduction program § Report repeated ABD or epigastric pain and vomiting or diarrhea that occur several weeks to months after surgery. · These symptoms indicate possible Postcholecystectomy Syndrome (PCS) · There are many causes of PCS: pseudocyst, common bile duct (CBD) leak, CBD/pancreatic duct obstruction or stricture, new gallstone, pancreatic or liver mass, sclerosing cholangitis, diverticular compression, CAD, neuritis, psychiatric disorder · Management depends on the cause, but usually involves the use of endoscopic retrograde cholangiopancreatography (ERCP) to find the cause and repair it.

percutaneous method or laparoscopy

Pancreatic Abscess 1. Pancreatic abscesses are the most serious complication of acute necrotizing pancreatitis. If untreated, they are always fatal. After surgery, the recurrence rate is high. 2. The abscesses form from collections of purulent liquefaction of the necrotic pancreas 3. Patients with Pancreatic abscesses often appear more seriously ill than those with pseudocysts. 4. S/S of Pancreatic abscesses are similar, but their temperature can spike as high as 104F. 5. Drainage via the ___________________________ should be performed ASAP to prevent sepsis. 6. Antibiotics alone will not resolve the abscess.

Venous thromboembolism

Pancreatic Cancer · Pancreatic Cancer is difficult to diagnose early because the pancreas is hidden and surrounded by other organs. Treatment has limited results and 5-year survival rates are low § Pancreatic tumors usually originate in the pancreatic ductal system. If the tumor is discovered early, the tumor cells may be localized in the glandular organ. But this is not common; most often, the tumor is discovered in the late stages of development and may be a well-defined mass or diffusely spread throughout the pancreas § The tumor can be a primary mass or result from metastasis of cancers of the lung, breast, thyroid, or skin. § Primary tumors are usually adenocarcinomas and grow in well-differentiated glandular patterns. They grow rapidly and spread to surrounding organs (stomach, duodenum, gallbladder, and intestine). The highly metastatic lesion may eventually invade the lung, peritoneum, liver, spleen, and lymph nodes § Signs and Symptoms of Pancreatic Cancer vary depending on the site of origin (head of pancreas is most common site). Jaundice results from tumor compression of bile duct § Cancers of the body and tail of the pancreas are usually large, and may be palpable ABD masses, especially in thin patients. · Metastasis to splenic vein or liver can cause hepatomegaly; then spreads quickly · Cancers can spread to the retroperitoneum, vertebral column, spleen, adrenal glands, colon, or stomach. · ___________________________________________ is a common complication of pancreatic cancer. Necrotic products of the pancreatic tumor are believed to have thromboplastic properties, resulting in increased hypercoagulability. Decreased mobility and extensive surgical manipulation also increase VTE risk.

1. Palpated as an epigastric mass 2. Epigastric pain radiating to the back 3. ABD fulness 4. Nausea/Vomiting 5. Jaundice 6. Complications: hemorrhage, infection, obstruction of bowel/biliary tract/splenic vein, abscess, fistula formation, pancreatic ascites

Pancreatic Pseudocyst · Pancreatic Pseudocysts (false cysts) are named so because, unlike true cysts, they do not have an epithelial lining. They are encapsulated, saclike structures that form on or surround the pancreas. § The Pancreatic Pseudocyst wall is inflamed, vascular, and fibrotic. It can contain several liters of straw-colored or brown viscous fluid, the enzymatic exudate of the pancreas § Risk factors: acute pancreatitis, ABD trauma, chronic pancreatitis · Signs and Symptoms of Pancreatic Pseudocysts: 1. 2. 3. 4. 5. 6. · Treatment for Pancreatic Pseudocysts: 1. May resolve spontaneously or may rupture and hemorrhage 2. Surgical intervention is needed if the Pancreatic Pseudocysts don't resolve in 6-8 weeks or if complication develop 3. To provide external drainage, the surgeon inserts a sump drainage tube to remove pancreatic secretions and exudate. 4. Pancreatic fistulas are common after surgery, and skin breakdown from pancreatic enzymes leaking on skin are a challenge to maintain.

small, frequent, moderate-high carbohydrate, high-protein, LOW-fat meals. Food should be BLAND with little spice.

Promoting Nutrition for Acute Pancreatitis 1. The patient is maintained on NPO status in the early stage of pancreatitis. Antiemetics for n/v are given PRN. 2. Patients who have severe pancreatitis and are unable to eat for 24-48 hours after onset may begin jejunal tube feedings unless paralytic ileus is present a. EARLY nutrition intervention enhances immune system functioning and can prevent worsening of inflammation. b. Enteral nutrition is preferred over TPN because it causes fewer episodes of glucose elevation 3. Weight patient every day!!! Collab with provider, dietician, and pharmacist to plan most appropriate nutritional intervention 4. When food is tolerated during the healing phase, the doctor prescribes a ___________________________________________________________________________________________________________ 5. GI stimulants (caffeine, tea, coffee, cola, chocolate, alcohol) should be AVOIDED. 6. Monitor during first few feedings for n/v/d. If these symptoms occur, report to provider 7. Commercial liquid nutritional preparations can boost caloric intake. The provider may prescribe fat-soluble and other vitamin/mineral supplements 8. Glutamine, omega-3 fatty acids, fiber, antioxidants, and/or nucleotides may be added to the nutrition plan.

holidays and vacations when alcohol consumption may be high, especially in men. Women are affected often after cholelithiasis and biliary tract problems. Also at risk in several months after childbirth

Risk Factors for Acute Pancreatitis 1. Biliary tract disease, with gallstones accounting for most causes of obstructive pancreatitis 2. Trauma from duodenal procedures (cholecystectomy, Whipple procedure, or ERCP) 3. External trauma (blunt trauma, stab wounds, GSW) 4. Pancreatic obstruction: tumors, cysts, abscesses, abnormal organ structure 5. Metabolic disturbances: hyperlipidemia, hyperparathyroidism 6. Renal disturbances: failure or transplantation 7. Familial, inherited pancreatitis 8. Penetrating gastric or duodenal ulcers, resulting in peritonitis 9. Viral infections, such as coxsackievirus B and HIV infection 10.Alcoholism 11.Drug toxicities: opiates, sulfonamides, thiazides, steroids, oral contraceptives 12.Smoking 13.Cystic fibrosis 14.Gallstones 15.ABD surgery 16.* !!! Pancreatic "attacks" may be common during ________________________________________. !!!*

1. Obesity 2. Type 2 diabetes mellitus, glucose intolerance 3. experiencing rapid weight loss 4. prolonged fasting 5. intestinal diseases affecting normal absorption of nutrients (Crohn's disease) 6. Nutrition habits: excessive dietary cholesterol intake

Risk Factors for Cholecystitis 1. 2. 3. 4. 5. 6. 7. Sedentary lifestyle 8. Family or genetic tendency; may be due to familial nutrition habits 9. Dyslipidemia 10. Insulin resistance 11. older age 12. female gender, hormone replacement therapy (HRT), estrogens, or oral contraceptives 13. Pregnancy 14. family history of gallstones 15. American Indian and Mexican-American or Caucasian 16. Cholesterol lowering drugs 17. Gastric bypass surgery 18. Sickle cell disease

1. Avoid irritants: alcohol, caffeine, spices, nicotine 2. Obtain help for alcoholism to help avoid alcohol ingestion 3. Eat bland, low-fat, low-spice , high-protein, moderate-carbohydrate frequent meals; avoid rich, fatty foods 4. Eat snacks high in calories 5. Adhere to pancreatic enzyme replacement. Take the enzymes before or at the beginning of meals and snacks to help digestion and promote absorption of fats/proteins. 6. Rest frequently; restrict activity to one floor until strength is regained.

Surgical Interventions for Chronic Pancreatitis 1. Surgery is indicated for ABD pain, relapses of pain, or complications like abscesses or pseudocysts. 2. Using laparoscopy, the surgeon incises and drains an abscess or pseudocyst 3. Laparoscopic cholecystectomy or choledochotomy may be indicated if biliary tract disease causes pancreatitis. 4. If the pancreatic duct sphincter is fibrotic, a sphincterotomy is done to enlarge it 5. A laparoscopic distal pancreatectomy may be needed for resection of the distal pancreas or the pancreas head. 6. In few cases, pancreatic transplantation may be done. This is done often for those with severe, uncontrolled diabetes. Home Care Coordination and Transition Management for Chronic Pancreatitis · Case management is needed for discharge planning and follow-up coordination · The living area of the home should be limited to one floor until the patient regains strength and can increase activity. Toilet facilities must be easily accessible due to chronic steatorrhea and frequent defecation (may need bedside commode) · Teach family how to prevent acute episodes of the disease (because there is no cure). 1. 2. 3. 4. 5. 6. · Written instructions are essential, with consideration of personal/cultural food preferences · Report increase in ABD distention, cramping, or foul-smelling/frothy/fatty stools · ABD fistulas are common and present a challenge because pancreatic secretions irritate the skin. · Keep skin dry and free of abrasive fatty stools, which damage the skin, when frequent stooling is a problem. Clean skin thoroughly after each stool. A moisture barrier may be needed. · If they develop DM, oral antidiabetics or insulin may be prescribed. Collab with a diabetic educator if this occurs.

B. 35-year-old American Indian who works in construction E. 64-year-old Mexican American who resides with grandchildren

The community nurse is talking with four clients who have reported digestive concerns. Which client does the nurse recognize as most likely to experience gallstone production? (SATA) A. 23-year-old Caucasian vegetarian who is a dancer B. 35-year-old American Indian who works in construction C. 48-year-old Canadian who manages a fast food restaurant D. 59-year-old Asian American who is an investment banker E. 64-year-old Mexican American who resides with grandchildren

c. "Let's talk about how you are feeling about your spouse's prognosis."

The hospice nurse is caring for a client with pancreatic cancer who has been given two to three months to live. What is the appropriate nursing response when the client's spouse states, "I know he is going to get better" ? a. Use therapeutic silence and say nothing. b. "Your spouse will die in 2-3 months." c. "Let's talk about how you are feeling about your spouse's prognosis." d. "If your spouse adheres to the entire treatment plan, recovery is possible."

d. Disseminated intravascular coagulation (DIC)

The nurse closely monitors the client with acute pancreatitis for which life-threatening complication? a. Jaundice b. Type I diabetes mellitus c. Abdominal pain d. Disseminated intravascular coagulation (DIC)

a. "You will have a small, midline abdominal incision." d. "Generally, the pain associated with this procedure is minimal." e. "This procedure has a low incidence of infection."

The nurse will include what post-operative teaching when caring for the client who is preparing to undergo endoscopic cholecystectomy? (Select all that apply.) a. "You will have a small, midline abdominal incision." b. "You cannot eat or drink for a few days after the procedure." c. "You will not be able to return to regular activity for several weeks." d. "Generally, the pain associated with this procedure is minimal." e. "This procedure has a low incidence of infection." f. "The hospital stay after this procedure is typically 3 to 4 days."

c. Dietary adjustments to include avoiding high-fat foods, caffeine, and alcohol

Which teaching will the nurse provide when discharging a client with chronic pancreatitis? a. Weight reduction and daily exercise regimen b. Constipation precautions including daily laxative use c. Dietary adjustments to include avoiding high-fat foods, caffeine, and alcohol d. Relaxation techniques and stress management

1. Pancreatic Infection (causes septic shock) 2. Hemorrhage (necrotizing hemorrhagic pancreatitis, NHP) 3. Jaundice occurs from swelling of the head of the pancreas, which slows bile flow through the common bile duct (bile duct may get compressed by stones or pancreatic pseudocyst). The resulting bile flow obstruction causes jaundice 4. Intermittent hyperglycemia occurs from release of glucagon (and decreased release of insulin due to damage to islet cells). Total destruction of the pancreas leads to T1DM 5. Left Lung Pleural Effusions develop with acute pancreatitis 6. Atelectasis and Pneumonia can occur, especially in older patients 7. Multisystem Organ Failure is caused by necrotizing hemorrhagic pancreatitis (NHP) 8. Acute Respiratory Distress Syndrome (ARDS): severe pulmonary edema caused by disruption of the alveolar capillary membranes (serious complication of pancreatitis).Pulmonary Failure accounts for more than half of all deaths in pancreatitis patients. 9. Coagulation Defects: Disseminated Intravascular Coagulation (DIC) involves hypercoagulation of the blood, with consumption of clotting factors and the development of microthrombi 10. Shock results from peripheral vasodilation and retroperitoneal loss of protein-rich fluid from proteolytic digestion 11. Hypovolemia may result in decreased renal perfusion, shock and Acute Renal Failure 12. Paralytic Ileus due to peritoneal irritation and seepage of pancreatic enzymes into the ABD cavity.

· Complications of Acute Pancreatitis: can be severe, life-threatening complications!!! 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12.

Intermittent hyperglycemia

· Complications of Acute Pancreatitis: can be severe, life-threatening complications!!! 1. Pancreatic Infection (causes septic shock) 2. Hemorrhage (necrotizing hemorrhagic pancreatitis, NHP) 3. Jaundice occurs from swelling of the head of the pancreas, which slows bile flow through the common bile duct (bile duct may get compressed by stones or pancreatic pseudocyst). The resulting bile flow obstruction causes jaundice 4. _____________________ occurs from release of glucagon (and decreased release of insulin due to damage to islet cells). Total destruction of the pancreas leads to T1DM 5. Left Lung Pleural Effusions develop with acute pancreatitis 6. Atelectasis and Pneumonia can occur, especially in older patients 7. Multisystem Organ Failure is caused by necrotizing hemorrhagic pancreatitis (NHP) 8. Acute Respiratory Distress Syndrome (ARDS): severe pulmonary edema caused by disruption of the alveolar capillary membranes (serious complication of pancreatitis). Pulmonary Failure accounts for more than half of all deaths in pancreatitis patients. 9. Coagulation Defects: Disseminated Intravascular Coagulation (DIC) involves hypercoagulation of the blood, with consumption of clotting factors and the development of microthrombi 10. Shock results from peripheral vasodilation and retroperitoneal loss of protein-rich fluid from proteolytic digestion 11. Hypovolemia may result in decreased renal perfusion, shock and Acute Renal Failure 12. Paralytic Ileus due to peritoneal irritation and seepage of pancreatic enzymes into the ABD cavity.

1. INCREASED serum AMYLASE (PANCREATIC cell injury) 2. INCREASED serum LIPASE (PANCREATIC cell injury) 3. INCREASED serum GLUCOSE (PANCREATIC cell injury and decrease insulin release) 4. Increased serum trypsin (pancreatic cell injury) 5. Increased serum elastase (pancreatic cell injury)

· Laboratory and Diagnostic Assessment of Acute Pancreatitis: 1. 2. 3. 4. 5. 6. Decreased serum calcium and magnesium (seen in fat necrosis) a. Calcium may fall and remain decreased for 7-10 days. Those that remain consistently below 8mg/dL are associated with poor prognosis 7. INCREASED BILIRUBIN (HEPATOBILIARY obstructive process) 8. ELEVATED ALANINE AMINOTRANSFERASE (ALT) (HEPATOBILIARY involvement). A threefold or greater risk in concentration indicates that diagnosis of acute biliary pancreatitis is valid 9. ELEVATED ASPARTATE AMINOTRANSFERASE (AST) (HEPATOBILIARYinvolvement) 10. Elevated leukocyte count (inflammatory response) 11. CMP, CBC: BUN, triglycerides elevated; hemoconcentration due to third-space fluid loss § Abdominal ultrasound is most sensitive test to diagnose the cause of pancreatitis, such as gallstones. It is NOT helpful in viewing the pancreas because of overlying bowel gas. § Contrast-enhanced CT provides reliable image and diagnosis of acute pancreatitis § ABD X-ray may show gallstones; pancreatic gallstones best diagnosed through ERCP

7. INCREASED BILIRUBIN (HEPATOBILIARY obstructive process) 8. ELEVATED ALANINE AMINOTRANSFERASE (ALT) (HEPATOBILIARY involvement). A threefold or greater risk in concentration indicates that diagnosis of acute biliary pancreatitis is valid 9. ELEVATED ASPARTATE AMINOTRANSFERASE (AST) (HEPATOBILIARYinvolvement)

· Laboratory and Diagnostic Assessment of Acute Pancreatitis: 1. INCREASED serum AMYLASE (PANCREATIC cell injury) 2. INCREASED serum LIPASE (PANCREATIC cell injury) 3. INCREASED serum GLUCOSE (PANCREATIC cell injury and decrease insulin release) 4. Increased serum trypsin (pancreatic cell injury) 5. Increased serum elastase (pancreatic cell injury) 6. Decreased serum calcium and magnesium (seen in fat necrosis) a. Calcium may fall and remain decreased for 7-10 days. Those that remain consistently below 8mg/dL are associated with poor prognosis 7. 8. 9. 10. Elevated leukocyte count (inflammatory response) 11. CMP, CBC: BUN, triglycerides elevated; hemoconcentration due to third-space fluid loss § Abdominal ultrasound is most sensitive test to diagnose the cause of pancreatitis, such as gallstones. It is NOT helpful in viewing the pancreas because of overlying bowel gas. § Contrast-enhanced CT provides reliable image and diagnosis of acute pancreatitis § ABD X-ray may show gallstones; pancreatic gallstones best diagnosed through ERCP

1. Elevated WBC indicates inflammation 2. Elevated serum alkaline phosphatase, aspartate aminotransferase (AST), and lactate dehydrogenase (LDH) indicate abnormalities in liver function (with severe biliary obstruction) 3. Elevated Direct (conjugated) and Indirect (unconjugated) Serum Bilirubin 4. Elevated Serum Amylase with pancreatic involvement

· Labs and Diagnostics for Cholecystitis: 1. 2. 3. 4. 5. X-ray: shows ONLY calcified gallstones (non-calcified stones can't be seen) 6. Ultrasonography (US) of the RIGHT UPPER QUADRANT is the best initial diagnostic test for Cholecystitis. Acute cholecystitis is seen as edema of the gallbladder and pericholecystic fluid 7. Hepatobiliary scan (HIDA scan) can be performed to visualize the gallbladder and determine patency of the biliary system. A radioactive tracer or chemical is injected IV. § About 20 minutes after injection, a gamma camera tracks the flow of the tracer from the gallbladder to determine the ejection rate of bile into the biliary duct § A decreased bile flow indicates gallbladder disease with obstruction § NPO prior to procedure 8. Endoscopic Retrograde Cholangiopancreatography (ERCP) may be done when the patient has symptoms of biliary obstruction and the cause of cholecystitis is unknown.

shows ONLY calcified gallstones (non-calcified stones can't be seen)

· Labs and Diagnostics for Cholecystitis: 1. Elevated WBC indicates inflammation 2. Elevated serum alkaline phosphatase, aspartate aminotransferase (AST), and lactate dehydrogenase (LDH) indicate abnormalities in liver function (with severe biliary obstruction) 3. Elevated Direct (conjugated) and Indirect (unconjugated) Serum Bilirubin 4. Elevated Serum Amylase with pancreatic involvement 5. X-ray: _____________________________________________________________ 6. Ultrasonography (US) of the RIGHT UPPER QUADRANT is the best initial diagnostic test for Cholecystitis. Acute cholecystitis is seen as edema of the gallbladder and pericholecystic fluid 7. Hepatobiliary scan (HIDA scan) can be performed to visualize the gallbladder and determine patency of the biliary system. A radioactive tracer or chemical is injected IV. § About 20 minutes after injection, a gamma camera tracks the flow of the tracer from the gallbladder to determine the ejection rate of bile into the biliary duct § A decreased bile flow indicates gallbladder disease with obstruction § NPO prior to procedure 8. Endoscopic Retrograde Cholangiopancreatography (ERCP) may be done when the patient has symptoms of biliary obstruction and the cause of cholecystitis is unknown.

HYPERGLYCEMIA OR HYPOGLYCEMIA due to stress and surgical manipulation of the pancreas. For those having a radical pancreatectomy, MONITOR GLUCOSE and give insulin as prescribed because the entire pancreas is removed.

· Postoperative Care for Surgical Treatment of Pancreatic Cancer: 1. Open Whipple Procedure is extensive and long, so maintaining fluid/electrolyte balance can be difficult. § They often have significant intra-operative blood loss and postoperative bleeding. Intestines are exposed to air for a long time and fluid evaporates. Losses of fluid can occur from NGT suction. Malnutrition can decrease protein and albumin. Reduction in osmotic pressure increases risk of third spacing (resulting in shock). · These problems are less likely with the MIS approach · Detect early s/s of hypovolemia and prevent shock · Monitor vitals for decreased BP, increased HR, decreased vascular pressures (using pulmonary artery catheter), decreased urine output; be alert for pitting edema of extremities, dependent edema in sacrum/back, and intake that far exceeds output · Maintain sequential compression devices to prevent DVT § Maintain prescribed IV isotonic fluid replacement with colloid replacement. § Monitor H/H to check for blood loss and need for transfusions § Check for decreased sodium, potassium, chloride, and calcium § Immediately after the Whipple Procedure, the patient may have __________________________________________________________________________________________________

clear, colorless, bile-tinged drainage or frank blood with an increase in output may indicate disruption or leakage of an anastomosis site. Most disruptions of the site occur within 7-10 days after surgery

· Postoperative Care for Surgical Treatment of Pancreatic Cancer: 1. Patients who have had an open radical pancreaticoduodenectomy require intensive nursing care and are usually admitted to the surgical ICU. 2. Patients who have had MIS have a shorter postop recovery period and less pain. Laparoscopic Whipple or pancreatectomy are at less risk for severe complications. 3. Observe for and implement preventative measures for these surgical complications 1. Immediately after surgery the patient is NPO and usually has an NG tube to decompress the stomach/ and are probably on a vent. Monitor GI drainage and tube patency. 2. In open surgical approaches, biliary drainage tubes are placed to remove secretions and prevent stress on the anastomosis sites. Monitor tubes and drainage devices for tension or kinking and maintain them in a dependent position § Monitor the drainage for color, consistency, and amount. Drainage should be serosanguineous. § The appearance of _______________________________________________________________________________________________ § Hemorrhage can occur as an early or late complication 3. Place the patient in the semi-Fowler's position to reduce tension on the suture line and anastomosis site and to optimize lung expansion. 4. Stress can be reduced by maintaining NGT drainage at a low or high intermittent suction level to keep the remaining stomach (if partial gastrectomy is done) or the jejunum (if a total gastrectomy is done) free of excessive fluid buildup and pressure. 5. The development of a fistula (abnormal passageway) is the most common and most serious postoperative complication. § Biliary, pancreatic, or gastric fistulas result from partial or total breakdown of an anastomosis site. Secretions that drain from the fistula contain bile, pancreatic enzymes, or gastric secretions (depending on which site is ruptured) § These secretions (especially pancreatic fluid) are corrosive and irritating to the skin; and internal leakage causes chemical peritonitis. § Peritonitis requires treatment with multiple antibiotics § If you suspect any postoperative complications resulting from MIS or open surgery, call the surgeon and report findings that support concerns.

1. Hemorrhage: from anastomosis; monitor pulse, BP, skin color, and mental status; which can cause HEART FAILURE and/or MI 2. Myocardial Infarction 3. Heart Failure 4. Thrombophlebitis

1. Paralytic (adynamic) Ileus 2. Bowel obstruction: bowel sounds and stools decreased 3. Liver Failure 4. Gastric retention and ulceration 5. Acute pancreatitis 6. Thrombosis to mesentery

involves extensive surgical manipulation and is used most often to treat cancer of the head of the pancreas. It entails removal of the proximal head of the pancreas, the duodenum, a portion of the jejunum, the stomach (partial or total gastrectomy), and the gallbladder, with anastomosis of the pancreatic duct(pancreatojejunostomy), and the stomach (gastrojejunostomy) to the jejunum. In addition, splenectomy may be performed.

· Preoperative Care for Surgical Treatment of Pancreatic Cancer: 1. Patients are often poor surgical candidates due to malnutrition and debilitation. 2. In late stages of pancreatic cancer or before the Whipple Procedure, the surgeon inserts a jejunostomy so enteral feedings can be given. This method is preferred to prevent reflux and facilitate absorption. a. Feedings started in low concentrations/volumes; gradually increased as tolerated b. Use a feeding pump for administration 3. TPN may be necessary in addition to tube feedings or as a single measure to provide adequate nutrition. When a central line is needed, a PICC or other IV line is needed. Meticulous IV line care is required to prevent sepsis. Sterile dressing changes and site observation are important. 4. For the laparoscopic procedure, no bowel preparation is needed. But either approach requires that the patient be NPO for at least 6-8 hours prior to surgery. · Operative Care for Surgical Treatment of Pancreatic Cancer: § Whipple Procedure (pancreaticoduodenectomy): __________________________________________________

1. Older age (60s-80s) 2. Smoking 3. Family history 4. DM 5. Chronic Pancreatitis 6. Cirrhosis 7. High Red Meat Intake, especially processed meat like steak 8. Long-Term Exposure to chemicals, like Gasoline, Pesticides 9. Obesity 10. Male Gender

· Risk Factors for Pancreatic Cancer: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10.

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