Meg Surg: Biliary Disorders

What is the most appropriate nursing diagnosis for the client with acute pancreatitis?

Deficient fluid volume Clients with acute pancreatitis often experience deficient fluid volume, which can lead to hypovolemic shock. Vomiting, hemorrhage (in hemorrhagic pancreatitis), and plasma leaking into the peritoneal cavity may cause the volume deficit. Hypovolemic shock will cause a decrease in cardiac output. Gastrointestinal tissue perfusion will be ineffective if hypovolemic shock occurs, but this wouldn't be the primary nursing diagnosis.

A nurse is teaching a client about the cause of acute pancreatitis. The nurse evaluates the teaching as effective when the client correctly identifies which condition as a cause of acute pancreatitis?

Self-digestion of the pancreas by its own proteolytic enzymes Self-digestion of the pancreas by its own proteolytic enzymes, principally trypsin, causes acute pancreatitis. Of clients with acute pancreatitis, 80% had undiagnosed chronic pancreatitis. Gallstones enter the common bile duct and lodge at the ampulla of Vater, obstructing the flow of pancreatic juice or causing a reflux of bile from the common bile duct into the pancreatic duct, thus activating the powerful enzymes within the pancreas. Normally, these remain in an inactive form until the pancreatic secretions reach the lumen of the duodenum. Activation of the enzymes can lead to vasodilation, increased vascular permeability, necrosis, erosion, and hemorrhage.

A client is admitted to the health care facility with abdominal pain, a low-grade fever, abdominal distention, and weight loss. The physician diagnoses acute pancreatitis. What is the primary goal of nursing care for this client?

Relieving abdominal pain The predominant clinical feature of acute pancreatitis is abdominal pain, which usually reaches peak intensity several hours after onset of the illness. Therefore, relieving abdominal pain is the nurse's primary goal. Because acute pancreatitis causes nausea and vomiting, the nurse should try to prevent fluid volume deficit, not overload. The nurse can't help the client achieve adequate nutrition or understand the disease and its treatment until the client is comfortable and no longer in pain.

There are two major types of gallstones:

those composed predominantly of pigment and those composed primarily of cholesterol. Pigment stones probably form when unconjugated pigments in the bile precipitate to form stones; these stones account for 10% to 25% of cases in the United States. There are no gallstones with the names of pearl, patterned, or pixelated.

Which is a clinical manifestation of cholelithiasis?

Clay-colored stools The client with gallstones has clay-colored stools and excruciating upper right quadrant pain that radiates to the back or right shoulder. The excretion of bile pigments by the kidneys makes urine very dark. The feces, no longer colored with bile pigments, are grayish (like putty) or clay colored. The client develops a fever and may have a palpable abdominal mass.

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

"Inflammation is confined to only the pancreas." There are two forms of pancreatitis-inflammatory and necrotizing. Inflammatory pancreatitis is confined to the pancreas only and normal function returns after about 6 months. Necrotizing pancreatitis is life-threatening and tissue necrosis occurs within the pancreas as well as the surrounding glands.

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

"The stones formed from a component in the bile and are caused by bile acid and fat abnormalities in the bloodstream." There are two types of gallstones-cholesterol and pigment. Cholesterol gallstones are formed from cholesterol (a component in the bile) and are caused by a decrease in bile acid synthesis and increased cholesterol synthesis. Pigment gallstones are formed by unconjugated pigment in the bile.

Pharmacologic therapy frequently is used to dissolve small gallstones. It takes about how many months of medication with UDCA or CDCA for stones to dissolve?

6 to 12 Ursodeoxycholic acid (UDCA [URSO, Actigall]) and chenodeoxycholic acid (chenodiol or CDCA [Chenix]) have been used to dissolve small, radiolucent gallstones composed primarily of cholesterol. Six to 12 months of therapy are required in many clients to dissolve stones, and monitoring of the client for recurrence of symptoms or occurrence of side effects (eg, GI symptoms, pruritus, headache) is required during this time.

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

Clay-colored feces Pruritus Jaundice Jaundice occurs in a few patients with gallbladder disease, usually with obstruction of the common bile duct. The bile, which is no longer carried to the duodenum, is absorbed by the blood and gives the skin and mucous membranes a yellow color. This is frequently accompanied by marked pruritus (itching) of the skin. The excretion of the bile pigments by the kidneys gives the urine a very dark color. The feces, no longer colored with bile pigments, are grayish (like putty) or clay colored.

The nurse should assess for an important early indicator of acute pancreatitis, which is a prolonged and elevated level of:

Serum lipase Serum amylase and lipase levels are elevated within 24 hours of the onset of symptoms. Serum amylase usually returns to normal within 48 to 72 hours, but serum lipase levels may remain elevated days longer than amylase.

A client with acute pancreatitis has been started on total parenteral nutrition (TPN). Which action should the nurse perform after administration of the TPN?

Measure blood glucose concentration every 4 to 6 hours Enteral or parenteral nutrition may be prescribed. In addition to administering enteral or parenteral nutrition, the nurse monitors the serum glucose concentration every 4 to 6 hours.

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

Pancreatic necrosis Pancreatic necrosis is a major cause of morbidity and mortality in clients with acute pancreatitis. Shock and multiple organ failure may occur with acute pancreatitis. Tetany is not a major cause of morbidity and mortality in clients with acute pancreatitis.

A client has a nasogastric (NG) tube for suction and is NPO after a pancreaticoduodenectomy. Which explanation made by the nurse is the major purpose of this treatment?

"The tube allows the gastrointestinal tract to rest." Postoperative management of clients who have undergone a pancreatectomy or a pancreaticoduodenectomy is similar to the management of clients after extensive gastrointestinal or biliary surgery. An NG tube with suction and parenteral nutrition allow the gastrointestinal tract to rest while promoting adequate nutrition.

A nurse is caring for a client diagnosed with cholelithiasis. Which of the following would be most appropriate for a client who is experiencing biliary colic?

Administer analgesics to the client. The pain of acute cholecystitis may be so severe that the client requires analgesics. During an attack of biliary colic, the nurse should ensure that the client rests. The nurse should not give the client a full meal; instead, the nurse should monitor the client's ability to digest a bland liquid diet. The nurse should also administer antispasmodics or analgesics as prescribed to relieve pain and discomfort.

A client with a history of alcohol abuse comes to the emergency department and complains of abdominal pain. Laboratory studies help confirm a diagnosis of acute pancreatitis. The client's vital signs are stable, but the client's pain is worsening and radiating to his back. Which intervention takes priority for this client?

Administering morphine I.V. as ordered The nurse should address the client's pain issues first by administering morphine I.V. as ordered. Placing the client in a Semi-Fowler's position, maintaining NPO status, and providing mouth care don't take priority over addressing the client's pain issues.

An older adult client is diagnosed with acute pancreatitis. Using what the nurse understands about gerontologic considerations related to acute pancreatitis, what concept does the nurse understand?

As the client ages, there is an increased mortality rate for acute pancreatitis. As the client ages, there is an increased risk for the development of multiple organ dysfunction syndrome. As the client ages, the pattern of complications related to acute pancreatitis changes. Gerontologic considerations must be remembered when caring for older adult clients with acute pancreatitis. Clients of all ages may develop acute pancreatitis; however, mortality rate for acute pancreatitis increases as the client ages. Additionally, as the client ages, the pattern of complications related to acute pancreatitis changes and the risk of developing multiple organ dysfunction syndrome (MODS) increases with age. The size of the pancreas does not decrease as the client ages.

Which intervention should be included in the plan of care for a client who has undergone a cholecystectomy?

Assessing the color of the sclera every shift If bile is not draining properly, an obstruction is probably causing bile to be forced back into the liver and bloodstream. Because jaundice may result, the nurse should assess the color of the sclerae.

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

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

The nurse cares for a client with gallstones that need to be removed but is not a surgical candidate or endoscopic candidate. What procedure does the nurse recognize as being a possible treatment option for the client?

ESWL Extracorporeal shock wave therapy, (ESWL) also known as lithotripsy, uses shock waves to break up gallstones for their removal and does not involve surgery or endoscopy. The other answer choices are performed by endoscopy.

When the nurse is caring for a patient with acute pancreatitis, what intervention can be provided in order to prevent atelectasis and prevent pooling of respiratory secretions?

Frequent changes of positions Frequent changes of position are necessary to prevent atelectasis and pooling of respiratory secretions.

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

Place the client in semi-Fowler's position. A client with severe biliary colic is in extreme pain and has a very difficult time taking a deep breath due to severe pain on inspiration. Placing the client in upright or semi-Fowler's position best promotes adequate breathing and best supports the client's function. Ambulation, deep breathing and coughing, and incentive spirometry may be too difficult or impossible for the client with severe biliary colic symptoms.

A client is diagnosed with gallstones in the bile ducts. The nurse knows to review the results of blood work for a

Serum bilirubin level greater than 1.0 mg/dL Jaundice occurs in a few clients with gallbladder disease, usually with obstruction of the common bile duct. If the flow of bile is impeded (eg, by gallstones in the bile ducts), bilirubin does not enter the intestine. As a result, blood levels of bilirubin increase.

The nurse is planning care for a client following an incisional cholecystectomy for cholelithiasis. Which intervention is the highest nursing priority for this client?

Assisting the client to turn, cough, and deep breathe every 2 hours Assessment should focus on the client's respiratory status. If a traditional surgical approach is planned, the high abdominal incision required during surgery may interfere with full respiratory excursion. The other nursing actions are also important, but are not as high a priority as ensuring adequate ventilation.

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

Edema and inflammation Mild acute pancreatitis is characterized by edema and inflammation confined to the pancreas. Minimal organ dysfunction is present, and return to normal function usually occurs within 6 months.

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

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

Which enzyme aids in the digestion of fats?

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

A client with acute pancreatitis reports muscle cramping in the lower extremities. What pathophysiology concept represents the reason the client is reporting this?

Tetany related to hypocalcemia A client with acute pancreatitis who reports muscle cramping or pain should be suspected of having hypocalcemia and tetany of the muscles. Hypocalcemia may occur in acute pancreatitis because, when auto digestion of the pancreas occurs, calcium binds to fatty acids and calcium is decreased in the blood. This is a potentially life-threatening complication of pancreatitis and needs to be immediately addressed.

When caring for a client with acute pancreatitis, the nurse should use which comfort measure?

Positioning the client on the side with the knees flexed The nurse should place the client with acute pancreatitis in a side-lying position with knees flexed; this position promotes comfort by decreasing pressure on the abdominal muscles. The nurse should administer an analgesic, as needed and ordered, before pain becomes severe, rather than once each shift. Because the client needs a quiet, restful environment during the acute disease stage, the nurse should discourage frequent visits from family and friends. Frequent oral feedings are contraindicated during the acute stage to allow the pancreas to rest.

Several clinical manifestations are associated with a tumor of the head of the pancreas. Choose all that apply.

Clay-colored stools Dark urine Jaundice Sixty to eighty percent of pancreatic tumors occur in the head of the pancreas. Tumors in this region obstruct the common bile duct. The obstructed flow of bile produces jaundice, clay-colored stools, and dark urine. Malabsorption of nutrients and fat-soluble vitamins may result if the tumor obstructs the entry of bile to the gastrointestinal tract. Abdominal discomfort or pain and pruritus may be noted, along with anorexia, weight loss, and malaise. If these signs and symptoms are present, cancer of the head of the pancreas is suspected.

A client diagnosed with acute pancreatitis is being transferred to another facility. The nurse caring for the client completes the transfer summary, which includes information about the client's drinking history and other assessment findings. Which assessment findings confirm his diagnosis?

Recent weight loss and temperature elevation Assessment findings associated with pancreatitis include recent weight loss and temperature elevation. Inflammation of the pancreas causes a response that elevates temperature and leads to abdominal pain that typically occurs with eating. Nausea and vomiting may occur as a result of pancreatic tissue damage that's caused by the activation of pancreatic enzymes. The client may experience weight loss because of the lost desire to eat. Blood in stools and recent hypertension aren't associated with pancreatitis; fatty diarrhea and hypotension are usually present. Presence of easy bruising and bradycardia aren't found with pancreatitis; the client typically experiences tachycardia, not bradycardia. Adventitious breath sounds and hypertension aren't associated with pancreatitis.

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

Ultrasonography Ultrasonography has replaced cholecystography (discussed later) as the diagnostic procedure of choice because it is rapid and accurate and can be used in patients with liver dysfunction and jaundice. It does not expose patients to ionizing radiation.

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

Weight loss Weight loss is most common in the client with chronic pancreatitis due to decreased dietary intake secondary to anorexia or fear that eating will precipitate another attack. The other answer choices are not the most common complications related to chronic pancreatitis.

A nurse is preparing a client for endoscopic retrograde cholangiopancreatography (ERCP). The client asks what this test is used for. Which statements by the nurse explains how ERCP can determine the difference between pancreatitis and other biliary disorders? Select all that apply.

"It can evaluate the presence and location of ductal stones and aid in stone removal." "It can assess the anatomy of the pancreas and the pancreatic and biliary ducts." "It can detect unhealthy tissues in the pancreas and assess for abscesses and pseudocysts." ERCP can determine the difference between pancreatitis and other biliary disorders and is generally used in chronic pancreatitis. It is particularly useful in diagnosis and treatment of clients who have symptoms after biliary tract surgery, clients with intact gallbladders, and clients for whom surgery is particularly hazardous. It can be used to assist with the removal of stones. ERCP is a useful tool in providing anatomic details about the pancreas and biliary ducts. It can evaluate the presence and location of ductal stones and detect changes in the anatomy of the client with pancreatitis, such as obstruction in the pancreatic duct and tissue necrosis due to premature release of pancreatic enzymes, and assess for abscesses and pseudocysts and atrophy of the glands in the body. ERCP is rarely used in the diagnostic evaluation of acute pancreatitis because the clients is acutely ill; however, it may be valuable in treating gallstone pancreatitis.

A client admitted with severe epigastric abdominal pain radiating to the back is vomiting and reports difficulty breathing. Upon assessment, the nurse determines that the client is experiencing tachycardia and hypotension. Which actions are priority interventions for this client?

Administer pain-relieving medication Administer electrolytes Administer plasma Assist the client to a semi-Fowler position The nurse promptly reports decreased blood pressure (BP) and reduced urine output, which indicate hypovolemia and shock or renal failure. The treatment goals for acute pancreatitis focus on relieving pain, maintaining circulatory and fluid volume, and decreasing the production of pancreatic enzymes. Intravenous replacement of fluid and electrolytes should begin immediately because of the loss of fluid in the body. If hypotension is evident, plasma should be administered to maintain BP within an acceptable range. Fluids are administered intravenously and may be accompanied by infusion of blood or blood products to maintain blood volume and to prevent or treat hypovolemic shock. Low serum calcium and magnesium concentrations may occur and require prompt treatment. The nurse maintains the client in a semi-Fowler position to decrease pressure on the diaphragm by a distended abdomen and to increase respiratory expansion. A low-fat diet, with small frequent meals, should be initiated after control of symptoms; it is not an immediate priority.

A client is admitted to the healthcare facility suspected of having acute pancreatitis and undergoes laboratory testing. Which of the following would the nurse expect to find?

Elevated urine amylase levels Elevated serum and urine amylase, lipase, and liver enzyme levels accompany significant pancreatitis. If the common bile duct is obstructed, the bilirubin level is above normal. Blood glucose levels and white blood cell counts can be elevated. Serum electrolyte levels (calcium, potassium, and magnesium) are low.

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

High-carbohydrate, low-protein, low-fat diet The nurse should provide a high-carbohydrate, low-protein, low-fat diet when tolerated. These foods increase caloric intake without stimulating pancreatic secretions beyond the ability of the pancreas to respond.