Concepts: Cholecystitis and Pancreatitis
Case study info
-Pancreatitis can causes exudate to go into the lymph nodes and irritate the diaphragm and cause breathing issues -Want to be on bowel rest -Have side lying (SIM) -We have 2L of gastric juices in our body -We usually put these ppl on a NGT tube to avoid causing irritation to the stomach -Always if pt has a low Ca means they are in the worst condition for pancreatitis -We can't just change the rate of TPN without an order; they usually have electrolytes or insulin. Also if it runs out just attach them to IV dextrose -Want low fat -S/S of biliary tract issues: clay/tan colored stools,
Complications
-SIRS -Pancreatic abscess -Pulmonary problems: ARDS, -Pleural effusion, atelectasis, PNA -Splanchinic venous thrombosis
Conservative therapies
Cholelithiasis: -Lithotripsy: shockwave therapy to break down stones' needs to repeated; can have reoccurrence of stones in five years -Medications: Bile acids that can break down stones. Not often given. Anti-inflammatories. -Ursodiol: takes forever to work Cholecystitis: -Pain control, treat infections with antibiotics, fluid and electrolyte balance. -Pts who are NPO or on TPN for long periods of time at risk. because bile is only released when stimulated
A client is admitted to the hospital for medical management of acute pancreatitis. Which nursing action is most likely to reduce the pancreatic and gastric secretions of a client with pancreatitis?
Administering prescribed anticholinergic medication. Rationale: Anticholinergic drugs block the neural impulses that stimulate pancreatic and gastric secretions; they inhibit the action of acetylcholine at postganglionic cholinergic nerve fibers. Oral fluids stimulate pancreatic secretion and are contraindicated. - Morphine sulfate is an analgesic and therefore does not decrease gastric secretions; in the past morphine sulfate was contraindicated for pain control with pancreatitis because it can precipitate spasms of the smooth musculature of the pancreatic ducts and the sphincter of Oddi. However, recent research indicates that it is the drug of choice over meperidine hydrochloride because the metabolites of meperidine hydrochloride can cause central nervous system irritation and seizures. The semi-Fowler position decreases pressure against the diaphragm; it will not decrease pancreatic secretions.
S/S
-Encephalopathy if the levels of bilirubin increases -high bili -Changes in LOC -Yellow skin -Urine turns brown/oily -Clay colored stools: high fat that causes them too float ; diarrhea -Pain/abdominal pain -Murphys sign: inflammation of the gallbladder -Pain after eating -ADEK vitamins (k being the big one) because the pancreas is not able to release enzymes to absorb these vitamins= bleeding How do we know whether or bili is related to an opbstrcution of the gallbladder emptying or the liver -Labs -red blood cells Brocken down (conjugated) then move out to be bile -If we have a high level of conjugated biliruben I know my liver is still converting bili but not excrete it= problem with gallbladder -Unconjugated: If RBC enter liver but can't break them down, then it can't conjugate them and have a rise in unconjugated bili= problem with liver Murphys sign - push up of the tight upper quadrant, and when the pt inhaled the gallbladder is going to rub up against your hand and its going to be painful; upon inspiration
T-Tube
-Excessive inflammation of the cystic or common duct can warrant a T-Tuve -It's a stent that keeps the duct open until the inflammation goes down -If we see a leakage around the bad there could be a new leakage -Bile should free flow into this bad (gravity drainage); DO NOT ATTACH to suction -If bile is not free floating into the bad the pt will complain of more pain, fever -there shouldn't be much drainage
A nurse reviews the laboratory results of a client with acute pancreatitis. Which test is most significant in determining the client's response to treatment? Platelet count Amylase level Red blood cell count Erythrocyte sedimentation rate
-In 90% of clients with acute pancreatitis, the amylase level is elevated up to three times over baseline; serum amylase usually returns to expected adult levels within three days after treatment begins. -The platelet count is not an indicator of the response to treatment for pancreatitis; platelets are important in the control of bleeding. -The red blood cell count is unchanged in acute pancreatitis, unless hemorrhage is present. The erythrocyte sedimentation rate is not an indicator of a response to treatment for pancreatitis.
A client is admitted with the diagnosis of acute pancreatitis. Which clinical manifestations should a nurse assess in the client? Select all that apply. Jaundice Acute pain Hypertension Hypoglycemia Increased amylase
-Jaundice -Acute pain -Increased amylase. Rationale: Obstruction of the common bile duct by inflammation leads to jaundice. Autodigestion of the pancreas causes severe abdominal pain. Obstruction of the pancreatic duct leads to elevated levels of amylase and lipase. -Hypotension, not hypertension, is caused by fluid shifting out of the intravascular space. -Decreased pancreatic function causes hyperglycemia, not hypoglycemia.
Chronic pancreatitis
-Pancreas is progressively destroyed and is replaced by fibrotic tissue. -Same causes as acute -Some acute cases develop into chronic pancreatitis. -Calcificaion.stones -Risk for cancer -Diabetes
Treatment
-Similar to acute -Smoking and alcohol cessation Dietary control: help control symptoms with diet management - Pancreatic insufficiency: Pancreatic enzyme replacement
Cholelithiasis
-best way to view these stones is not through a CT scan -Big calcium deposits won't show on CT scan but rather an ultrasound will -Populaions at risk: native Americans, pregnant women because of hormone producion How to prevent it -Decreasing obesity -Moving around -Make sure if a pt comes in for potential cholelithiasis we keep them NPO to avoid increase disc comfort -You can have cholithiasis without infection because of the blockage -Don't give metformin if pt is going to get a ERCP or CT (causes kidney damage) -Change a pt to insulin if they take metformin because we can highly control they're blood sugars with it; decreases potential for increase BS if infection -Low fat diet is preferred -Increase in bilirubin will be excreted in urine and it'll look orange because of the block of the cystic duct; caused by breakdown of RBC
Pancreas function
Lewis The pancreas is a long, slender gland lying behind the stomach and in front of the first and second lumbar vertebrae. -The pancreas has lobes and lobules. -The pancreatic duct extends along the gland and enters the duodenum through the common bile duct at the ampulla of Vater (Fig. 38.3). The exocrine function contributes to digestion through the production and release of enzymes Amylase: Starch to disaccharides Chymotrypsin: Protein digestion Lipase: Fat digestion Trypsinogen: Protein digestion -The endocrine function occurs in the islets of Langerhans, whose β cells secrete insulin and amylin: inhibits glucagon, delayed stomach secretion and satiety agent - α cells secrete glucagon; -δ cells secrete somatostatin: inhibits other hormones - F cells secrete pancreatic polypeptide.
The nurse prepares an intravenous solution of lactated Ringer solution to replace the T-tube output of a client who had a cholecystectomy and common bile duct exploration. Which condition will improve if the administration of lactated Ringer solution is effective?
Metabolic acidosis. Rationale: Lactated Ringer solution is an alkaline solution that replaces bicarbonate ions lost from T-tube bile drainage, thus preventing or treating acidosis. Urinary stasis is unrelated to the effectiveness of the administration of intravenous lactated Ringer solution. Paralytic ileus is unrelated to the effectiveness of the administration of intravenous lactated Ringer solution. An increased potassium level is unrelated to the effectiveness of the administration of intravenous lactated Ringer solution. Bile collects bicarbonate that had run through the small intestine to neutralize the acids of the stomach. So vomiting = loss of acids, but once it's been through the stomach you're looking at bicarbonate loss (intestinal fistulas and diarrhea).
Clinical Man
-Abdominal pain, may have periodic episodes. -Malabsorption with weight loss, mild jaundice, steatorrhea.
pseudocyesis
-Form inside pancreas -Become infected Cause symptoms -Abdominal pain -Gastric outlet obstruction - Biliary obstruction - Require drainage if infection or symptoms occur
Lewis Paralytic ileus
A nonmechanical obstruction occurs with reduced or absent peristalsis due to altered neuromuscular transmission of the parasympathetic innervation to the bowel. It may result from a neuromuscular or vascular disorder. -Paralytic ileus (lack of intestinal peristalsis and bowel sounds) is the most common form of nonmechanical obstruction. -It occurs to some degree after any abdominal surgery. It can be hard to know if a postoperative obstruction is due to paralytic ileus or adhesions. -One clue is that bowel sounds usually return before postoperative adhesions develop. -Other causes of paralytic ileus include peritonitis, inflammatory responses (e.g., acute pancreatitis, acute appendicitis), electrolyte abnormalities (especially hypokalemia), and thoracic or lumbar spinal fractures.
Which clinical indicator should the nurse identify before scheduling a client for an endoscopic retrograde cholangiopancreatography (ERCP)? Urine output Bilirubin level Blood pressure Serum glucose
Bilirubin level ERCP involves the insertion of a cannula into the pancreatic and common bile ducts during an endoscopy. The test is not performed if the client's bilirubin level is more than 3 to 5 mg/dL (51 to 85 mcmol/L) because cannulation may cause edema, which will increase obstruction of bile flow. Urine output, blood pressure, and serum glucose are not related directly to this test.
Diagnostics cont
CT scan for pseudocysts - ERCP (when pancreatitis is related to cholycystitis) -MRCP: magnetic resonance cholangiopancreatography -Amylase/Lipase: both elevated means it is a pancreatitis issue -Calcium/phosphorus -Troussers and Chovolkes -Increased WBC, Hyperglycemia -CT scan not the best because if the vessels of the pancreas are damaged the organ wont show. -ERCP can affect amylase levels which use contrast and cause damage of the pancreas ; dont use for pancreatitis unless we believe its caused by the gallstone from the cholelithiasis -MRCP
Physical Ass
Other areas of ecchymoses are the flanks (Grey Turner' spots or sign, a bluish flank discoloration) and the periumbilical area (Cullen's sign not specific to just pancreatitis , a bluish periumbilical discoloration). These result from seepage of bloodstained exudate from the pancreas and may occur in severe cases. Grey turner: bleeding in the retroperitoneal space; not specific to pancreatitis
ERCP:Endoscopic retrograde cholangio-pancreatography
Procedure that is both treatment and diagnostic -Put on versed or Midazalem for conscious sedation -
A nurse in the postanesthesia care unit (PACU) is providing care to a client who had an abdominal cholecystectomy and observes serosanguineous drainage on the abdominal dressing. What is the next nursing action? Change the dressing. Reinforce the dressing. Replace the tape with Montgomery ties. Support the incision with an abdominal binder.
Reinforce the dressing. The nurse should anticipate drainage and reinforce the surgical dressing as needed. Changing a dressing at this time is unnecessary and increases the risk for infection. Montgomery ties are used when frequent dressing changes are anticipated; they are not appropriate at this time. An abdominal binder rarely is prescribed, and it will interfere with assessment of the dressing at this time.
A client is admitted to the hospital with Laënnec cirrhosis and chronic pancreatitis. Bile salts (bile acid factor) are prescribed, and the client asks why they are needed. What is the nurse's best response? "They stimulate prothrombin production." "They aid absorption of fat-soluble vitamins." "They promote bilirubin secretion in the urine." "They help the common bile duct contract stronger."
"They aid absorption of fat-soluble vitamins." Rationale: Bile salts are used to aid digestion of fats and absorption of the fat-soluble vitamins A, D, E, and K. Bile salts are not involved in stimulating prothrombin production, in promoting bilirubin secretion in the urine, or in stimulating contraction of the common bile duct.
Anatomy
-Conditions of the gallbladder Gallbladder (stores bile) -when stimulated, releases bile in the presence of fats -Bile is released from the cystic doc down the common bile duct and empties into the duodenum -Bile helps with the absorption's of certain vitamins -People with high cholesterol levels will have high bile -High bilirubewe is the result of RBC brockendown down -Bile is formed in the liver (bile salts, cholesterol, biliruben)
Post surgical
-Continuous flow of bile rather than intermittent, can sometimes irritate the duodenum - Ambulate patient (especially if laparoscopic). -Decrease fat intake, small meals in the beginning. -May have some intolerance to some foods.( nausea and irritation) -Can have fat just watch what they eat -Smaller meals
Post surgical interventions
-Laparoscopic vs open, EBL, medications, typical outcome. -Watch for recovery from anesthesia - Pain management (phrenic pain from CO2 in laparoscopic procedure). -Incentive spirometry -Sims postion (lying of left side with right knee flexed) can help co2 gas out and not irritate the phrenic nerve -ambulaion helps more
Conservative treatment
-Supportive care -Pain management -Avoid anticholinergic meds when paralytic ileus is present. - NPO, pt may need NGT to "rest" the pancreas/duodenum -Antibiotics if infection is present
Diagnostics
-Ultrasound is gold standard -Shows gallstones that can't be seen with CT scan -Can do a CT scan if the gallstones re big enough or have enough calcium -Amylase and lipase for pancreatic enzymes -Increases WBC -Elevated liver function tests: LFT due to backup of bili to the liver -ERPS
Acute pancreatitis
Acute: Auto-digestion of the pancreas, spillage or activation of enzymes in the pancreas itself, rather than the duodenum (has bicarb to neutralize stomach acid). -Necrotizing acute pancreatitis -Other Causes: Smoking, genetic factors, long-term TPN (high lipids that are liquid), alcohol -gal-stones number one cause of pancreatitis -IF we keep this patient hypovolemic or hypotensive they have a greater risk of putting them in necrotising pancreatitis Lewis info The most common pathogenic mechanism in acute pancreatitis is autodigestion of the pancreas (Fig. 43.11). - The causative factors injure pancreatic cells or activate the pancreatic enzymes in the pancreas rather than in the intestine. -This may be due to reflux of bile acids into the pancreatic ducts through an open or distended sphincter of Oddi. -This reflux may be caused by blockage created by gallstones. Obstruction of pancreatic ducts results in pancreatic ischemia. -The exact mechanism by which chronic alcohol use predisposes a person to pancreatitis is not known. We think that alcohol increases the production of digestive enzymes in the pancreas.
A client is admitted to the hospital with slight jaundice and reports of pain on the left side and back. A diagnosis of acute pancreatitis is made. Which common response to acute pancreatitis should the nurse monitor in the client?
Hypovolemia that results from a fluid shift from the intravascular compartment to the peritoneal cavity can cause circulatory collapse; this is a life-threatening event that requires immediate intervention. -Crackles indicate an accumulation of fluid in the alveoli associated with hypervolemia, not hypovolemia. Gastric reflux occurs with gastroesophageal reflux disease (GERD), not with pancreatitis. Jugular vein distention indicates hypervolemia, not hypovolemia.
Diagnostics
Labs: Serum amylase and lipase, electrolytes -Calcium: Chvostek's sign or Trousseau's sign
Surgical therapy
Laparoscopic cholecystectomy: symptomatic cholelithiasis -Open Cholecystectomy: 10% of patients -Inflate with abdominal with CO2 gas which irritated that phrenic nerve, diagram and pain sit elated to gas; allows for
A client who had a laparoscopic cholecystectomy reports pain in the shoulder. In what position should the nurse place the client?
Left Sims Rationale: Retained carbon dioxide can irritate the phrenic nerve. Placing the client in the left Sims position helps to move the gas pocket away from the diaphragm. Deep breathing and ambulation should be encouraged. Prone, supine, and Trendelenburg positions will not help to alleviate the problem but could aggravate the problem.
A client who has a history of alcohol abuse now has recurrent exacerbations of chronic pancreatitis. The nurse asks the client to obtain a stool specimen. When assessing the client's stool, what would the nurse expect to observe?
Steatorrhea Decreased secretion of lipase from the pancreas limits fat breakdown in the small intestine, resulting in increased fat content in feces; steatorrhea is soft, frothy, foul-smelling feces. -Melena refers to black, tarry stool containing digested blood; melena is caused by upper gastrointestinal bleeding. -Hard, dry stool reflects constipation; stools associated with pancreatitis are soft and frothy. -Ribbon-shaped stool is associated with obstruction of the descending or sigmoid colon.
Biliary Tract: Cholelithiasis and Cholecystitis
Cholecystitis: Inflammation of the gallbladder wall. Usually occurs together, but not always -Gallbladder that causes inflammation due to no stones: Acalculous. -Cholelithiasis: Stones in the gallbladder, can be lodged in the neck of the gallbladder or in the cystic duct -When bile gets super saturated and have issues getting rid of bile -immobility can cause it so sludge and form stones Sludgy bile can irritate the wall of the gallbladder which occurs with immunocompromised pts -can have inflammation without infection because of the stones passing the cystic duct and causing irritation of the vessel which causes inflammation=obstrucion -
A nurse provides teaching for a client who is scheduled for a cholecystectomy. In the initial postoperative period, the nurse explains that the most important part of the treatment plan is what? Early ambulation Coughing and deep breathing Wearing antiembolic elastic stockings Maintenance of a nasogastric tub
Coughing and deep breathing The client who has a cholecystectomy will have difficulty taking deep breaths and coughing because of the location of the surgical incision. Therefore it is important to instruct the client preoperatively to improve compliance with the procedure in the early postop period. Although ambulation, antiembolism stockings, and maintaining a nasogastric tube, if ordered, are important postoperative procedures, maintaining the airway and preventing further pulmonary problems is the priority.
The nurse is creating a dietary plan for a client with cholecystitis who has been placed on a modified diet. Which will be most appropriate to include in the client's dietary plan
Decrease fat intake to avoid stimulation of the cholecystokinin mechanism for bile release. Rationale: Fat intake stimulates cholecystokinin release that signals the gallbladder to contract, causing pain. Soft-textured foods are unnecessary. -Eating low-cholesterol foods to avoid further formation of gallstones is not true for all clients with cholecystitis; low-cholesterol foods are necessary if the cholecystitis is precipitated by cholelithiasis and the stones are composed of cholesterol. An increase in protein intake is necessary to promote tissue healing and improve energy reserves after a cholecystectomy, but is not as important as fat intake for cholecystitis.
Surgical
Drainage of necrotic fluid collections Cholecystectomy if gallstones are the cause of pancreatitis
Clinical Manifestations
Lewis: -Abdominal pain is the main manifestation of acute pancreatitis. The pain is due to distention of the pancreas, peritoneal irritation, and obstruction of the biliary tract. -The pain is usually in the left upper quadrant, but it may be mid-epigastric. It often radiates to the back due to the retroperitoneal location of the pancreas. The pain has a sudden onset. It is described as severe, deep, piercing, and continuous or steady. -Eating worsens the pain. -Pain is not relieved by vomiting and may be accompanied by flushing, cyanosis, and dyspnea. -nausea and vomiting, low-grade fever, leukocytosis, hypotension, tachycardia, and jaundice. -Abdominal tenderness with muscle guarding is common. -Bowel sounds may be decreased or absent. -Paralytic ileus may occur and causes marked abdominal distention. -The lungs are often involved with crackles present. -Intravascular damage from circulating trypsin (a proteolytic enzyme) may cause areas of cyanosis or greenish to yellow-brown discoloration of the abdominal wall. -Shock may occur from hemorrhage into the pancreas, toxemia from the activated pancreatic enzymes, or hypovolemia due to fluid shift into the retroperitoneal space (massive fluid shifts).
A client is admitted to the hospital with a diagnosis of acute pancreatitis. The health care provider's prescriptions include nothing by mouth and total parenteral nutrition (TPN). The nurse explains that the TPN therapy provides what benefit? Is the easiest method for administering needed nutrition Is the safest method for meeting the client's nutritional requirements Will satisfy the client's hunger without the discomfort associated with eating Will meet the client's nutritional needs without causing the discomfort precipitated by eating
Will meet the client's nutritional needs without causing the discomfort precipitated by eating Providing nutrients by the intravenous route eliminates pancreatic stimulation, therefore reducing the pain experienced with pancreatitis. TPN is used to meet the client's needs, not the nurse's needs. TPN creates many safety risks for the client. Hunger can be experienced with TPN therapy.
Surgical options
-Roux-en-Y pancreatojejunostomy -Whipple: Pancreaticoduodenectomy -Denervation procedures
A nurse is caring for a client with a diagnosis of acute pancreatitis and alcoholism. The client asks, "What does my drinking have to do with my diagnosis?" What effect of alcohol should the nurse include when responding?
Increases enzyme secretion and pancreatic duct pressure that causes backflow of enzymes into the pancreas. -Rationale: Alcohol stimulates pancreatic enzyme secretion and an increase in pressure in the pancreatic duct. The backflow of enzymes into the pancreatic interstitial spaces results in partial digestion and inflammation of the pancreatic tissue. The complete pathophysiology of this disease is not entirely understood but likely results from alcohol's effects on the small pancreatic ducts and acinar cells. Alcohol is believed to cause precipitation and increases the viscosity of pancreatic secretions, which leads to the development of protein plugs in the small ducts, which then form calculi, causing ulceration, scarring, and eventual acinar atrophy and fibrosis. Alcohol also leads to premature activation of trypsinogen and other digestive and lysosomal enzymes within the acinar cells themselves; this causes the pancreatic tissue to auto-digest and leads to further inflammation.
A primary healthcare provider diagnoses a client with acute cholecystitis with biliary colic. Which clinical findings should the nurse expect when performing a health history and physical assessment? Select all that apply.
Intolerance to foods high in fat. Pain that radiates to the right shoulder. Rationale: Interference with bile flow into the intestine will lead to an increasing inability to tolerate fatty foods. Although the gallbladder is in the upper right quadrant of the abdomen, when inflamed it can radiate to the right shoulder or scapula. Diarrhea with melena (black feces) is not associated with cholecystitis. Melena is tarry stools associated with upper gastrointestinal bleeding; diarrhea is associated with increased intestinal motility. Coffee-ground emesis is indicative of gastric bleeding; it is not associated with cholecystitis. Gnawing pain when the stomach is empty is associated with duodenal ulcers, not with cholecystitis.
A client has cholelithiasis with possible obstruction of the common bile duct. The nurse performs a nutritional assessment. What is the primary goal for this assessment?
To determine if deficient in vitamins A, D, and K Bile promotes the absorption of the fat-soluble vitamins. An obstruction of the common bile duct limits the flow of bile to the duodenum and thus the absorption of these fat-soluble vitamins. -Most clients have pain after eating a fatty meal and do not follow this diet, but this is expected in cholelithiasis and is not the primary goal. Dietary fiber is not relevant to the situation. Although adequate dietary protein is desirable for wound healing, it is unrelated to cholelithiasis.