Prep-U Chapter 50: Assessment and management of patients with biliary disorders, PrepU Chapter 50: Biliary Disorders, PANCREATIC REVIEW

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Which enzyme aids in the digestion of fats? -Lipase -Amylase -Secretin -Trypsin

-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.

Acute Pancreatitis - Desired Outcomes of Collaborative Care

1) Pain relief. 2) Reduce stimulation to the pancreas - Thereby specifically reducing enzyme production and release 3) Correct fluid & electrolyte imbalances. 4) Prevent shock, if it occurs, treat. 5) Prevent and treat infections. 6) Remove precipitating cause of pancreatitis if identifiable. Text has a table outlining the table CHECK IT!!!!!!!***

Pseudocyst - Describe

fluid filled, enzyme and exudate filled, capsule surrounded by a wall within the pancreas. May resolve on their own. Pseudo may rupture or perforate, causing more acute inflammation and peritonitis.

Which is a gerontological consideration associated with the pancreas? -Increased amount of fibrous material -Increased bicarbonate output -Increased rate of pancreatic secretion -Increased calcium absorption

-Increased amount of fibrous material An increase in fibrous material and some fatty deposition occurs in the normal pancreas of people older than 70 years of age. There is a decreased rate of pancreatic secretion and decreased bicarbonate output in older adults. Decreased calcium absorption may also occur.

One difference between cholesterol stones (left) and the stones on the right are that the ones on the right account for only 10% to 25% of cases of stones in the United States. What is the name of the stones on the right? -Pigment -Pearl -Patterned -Pixelated

-Pigment 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.

Acute Pancreatitis - Ambulatory and Home Care

Counseling Dietary teaching Patient/family teaching - Signs of infection, hyperglycemia, steatorrhea; Medications If chronic alcohol abuse is contributing factor, referral to counseling and/or substinence abuse my be needed. Advocate for pt to get prescribed smoking cessation aids. Diet: nutritional consult/dietitian consult recommended. Low fat, high carb diet preferred. Fats should be restricted as ther stim release of cholecystokinin, which contributes to gallbladder spasm, and stims enzyme secretion. Maintain regular healthy diet, and avoid fasting/crash dieting which can precipitate the attack. Teach: return of ab pain, discoloration of ab, or foul smelling stools may indicate pancreatic damage. Meds: take all yo meds, fool. Talk to doc before OTC meds, fool. DON'T DIE FOOL!!!!

Chronic Pancreatitis - Enzyme Therapy pt teaching

Needed when pts show signs of malabsorption or malnutrition - greasy, foul smelling stools; many frequent loose BMs/day; ab pain and bloat P meals; excess flatulence; continued or unintended wt loss despite adequate food and fluid intake. All PEP consist of amylase, lipase, and protease. More may be added if all or part of pancreas and ducts are/were removed. Enzymes must be taken with ALL MEALS AND SNACKS, and ANY DAIRY CONTAINING DRINKS. Take directly c the food!!! C first bite. Enzymes are inactivated by decreased gastric PH, SHOULD BE TAKEN P ANTI-ACIDS!!! Diet plan, should include timing of enzymes taken. Capsules can be taken whole c full glass of cold water, or can be sprinkled directly onto food. However, granules within capsule cannot be crushed or chewed, as it will release enzymes directly into mouth and esophagus. Still may irritate mouth, tongue, and lips. Pt should swallow as fast as possible. If on food, food should be swallowed and not linger in mouth. PTs should rinse mouth out well p eating, and wipe off lips.

Acute Pancreatitis - Mgmt of metabolic complications

depends on severity of attack and amount of tissue damaged. Assess for hyperglycemia d/t damage of endocrine function of the pancreas. Insulin production down d/t damage to prod cells. S/S of hyperglycemia may be present in NPO pts. Inflammation and infection introduce production of glucocorticoids which ^ serum glucose. As pt consumes calories, hyper may become more severe.

A nurse should monitor blood glucose levels for a patient diagnosed with hyperinsulinism. What blood value does the nurse recognize as inadequate to sustain normal brain function? -30 mg/dL -50 mg/dL -70 mg/dL -90 mg/dL

-30 mg/dL Hyperinsulinism is caused by overproduction of insulin by the pancreatic islets. Occasionally, tumors of nonpancreatic origin produce an insulinlike material that can cause severe hypoglycemia and may be responsible for seizures coinciding with blood glucose levels that are too low to sustain normal brain function (i.e., lower than 30 mg/dL [1.6 mmol/L]) (Goldman & Schafer, 2012; McPherson & Pincus, 2011).

A nursing instructor is explaining the pathophysiology and clinical manifestations of pancreatitis to a group of nursing students. The instructor evaluates the teaching as effective when a student correctly identifies which symptom as that most commonly reported by clients with pancreatitis? -Tarry, black stools and dark urine -Increased and painful urination -Increased appetite and weight gain -Severe, radiating abdominal pain

-Severe, radiating abdominal pain Severe abdominal pain is the major symptom of pancreatitis that causes the client to seek medical care. The pain occurs in the midepigastrium. Abdominal pain and tenderness and back pain result from irritation and edema of the inflamed pancreas. Pain is frequently acute in onset, occurring 24 to 48 hours after a very heavy meal or alcohol ingestion; it may be diffuse and difficult to localize.

What is a major concern for the nurse when caring for a patient with chronic pancreatitis? -Pain -Weight loss -Nausea -Mental status changes

-Weight loss Weight loss is a major problem in chronic pancreatitis. More than 80% of patients experience significant weight loss, which is usually caused by decreased dietary intake secondary to anorexia or fear that eating will precipitate another attack (Bope & Kellerman, 2011).

A nurse should monitor blood glucose levels for a patient diagnosed with hyperinsulinism. What blood value does the nurse recognize as inadequate to sustain normal brain function?

30 mg/dL Explanation: Hyperinsulinism is caused by overproduction of insulin by the pancreatic islets. Occasionally, tumors of nonpancreatic origin produce an insulinlike material that can cause severe hypoglycemia and may be responsible for seizures coinciding with blood glucose levels that are too low to sustain normal brain function (i.e., lower than 30 mg/dL [1.6 mmol/L]) (Goldman & Schafer, 2012; McPherson & Pincus, 2011).

Acute pancreatitis - hyyhyhyh

Enzymes not only released within the pancreas, but also within the abdominal cavity. Some are also absorbed systemically. FFAs are released into the blood as a result of the fats being destroyed. Hypocalcemia-Trousseu's sign, and Chvotskey's sign. Kal - can lead to acute resp. distress syndrome, shock, circulatory collapse, and death.

Acute Pancreatitis - Clinical Manifestations

N/V; fever; ^WBCs; hypoactive BS. In some, BS may be absent, and accompanied by abdominal distention. These findings may indicate paralytic ileus (complete cessation of peristalsis. In most pts, entire abdomen is tender, leading to guarding behavior. Jaundice MAY be present, especially in cases involving ductal obstruction. May have Cullen sign and/or Turner's sign. In addition to these common finding, severe may have: d/t ^ in vascular permeability and marked vasodilation from circulating Kallikrein's, pts may exhibit s/s of acute resp. distress, including fluid buildup in lungs. Shock (htn, tachycardia, tachypnea, progressive renal impairments, and ultimately multi-system organ failure.

A client who has been having recurrent attacks of severe abdominal pain over the past few months informs the physician about a 25-pound weight loss in the past year. The nurse attributes which factor as the most likely cause of this weight loss? -Vomiting after heavy meals -Skipping meals out of fear of painful attacks -Ingesting a low-fat diet to prevent abdominal pain -Malabsorption

-Skipping meals out of fear of painful attacks Weight loss is a major problem in chronic pancreatitis. More than 80% of clients experience significant weight loss, which is usually caused by decreased dietary intake secondary to anorexia or fear that eating will precipitate another attack.

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 -Diarrhea -Fatigue -Hypertension

-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.

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 -Teaching the client to choose low-fat foods from the menu -Performing range-of-motion (ROM) leg exercises hourly while the client is awake -Assisting the client to ambulate the evening of the operative day

-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.

The nurse identifies a potential collaborative problem of electrolyte imbalance for a client with severe acute pancreatitis. Which assessment finding alerts the nurse to an electrolyte imbalance associated with acute pancreatitis? -Muscle twitching and finger numbness -Paralytic ileus and abdominal distention -Hypotension -Elevated blood glucose concentration

-Muscle twitching and finger numbness Muscle twitching and finger numbness indicate hypocalcemia, a potential complication of acute pancreatitis. Calcium may be prescribed to prevent or treat tetany, which may result from calcium losses into retroperitoneal (peripancreatic) exudate. The other data indicate other complications of acute pancreatitis but are not indicators of electrolyte imbalance.

What is the most appropriate nursing diagnosis for the client with acute pancreatitis? -Deficient fluid volume -Excess fluid volume -Decreased cardiac output -Ineffective gastrointestinal tissue perfusion

-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 critical care nurse is caring for a client with acute pancreatitis. One potentially severe complication involves the respiratory system. Which of the following would be an appropriate intervention to prevent complications associated with the respiratory system? -Maintain the client in a semi-Fowler's position. -Administer enteral or parenteral nutrition. -Carry out wound care as prescribed. -Withhold oral feedings.

-Maintain the client in a semi-Fowler's position. The nurse maintains the client in the semi-Fowler's position to decrease pressure on the diaphragm by a distended abdomen and to increase respiratory expansion. Respiratory distress and hypoxia are common, and the client may develop diffuse pulmonary infiltrates, dyspnea, tachypnea, and abnormal blood gas values. The client who has undergone surgery may have multiple drains or an open surgical incision and is at risk for skin breakdown and infection. Oral food or fluid intake is not permitted; therefore, enteral or parenteral feedings may be prescribed.

A client being treated for pancreatitis faces the risk of atelectasis. Which of the following interventions would be important to implement to minimize this risk? -Monitor pulse oximetry every hour. -Withhold oral feedings for the client. -Instruct the client to avoid coughing. -Reposition the client every 2 hours.

-Reposition the client every 2 hours.Repositioning the client every 2 hours minimizes the risk of atelectasis in a client who is being treated for pancreatitis. The client should be instructed to cough every 2 hours to reduce atelectasis. Monitoring the pulse oximetry helps show changes in respiratory status and promote early intervention, but it would do little to minimize the risk of atelectasis. Withholding oral feedings limits the reflux of bile and duodenal contents into the pancreatic duct.

Which nursing action is most appropriate for a client hospitalized with acute pancreatitis? -Withholding all oral intake, as ordered, to decrease pancreatic secretions -Administering meperedine, as ordered, to relieve severe pain -Limiting I.V. fluids, as ordered, to decrease cardiac workload -Keeping the client supine to increase comfort

Withholding all oral intake, as ordered, to decrease pancreatic secretions Explanation: The nurse should withhold all oral intake to suppress pancreatic secretions, which may worsen pancreatitis. Typically, this client requires a nasogastric tube to decompress the stomach and GI tract. Although pancreatitis may cause considerable pain, it's treated with I.M. meperidine (Demerol), not morphine, which may worsen pain by inducing spasms of the pancreatic and biliary ducts. No clinical evidence supports the use of meperidine for pain relief in pancreatitis, and, in fact, accumulation of its metabolites can cause CNS irritability and possibly seizures. Pancreatitis places the client at risk for fluid volume deficit from fluid loss caused by increased capillary permeability. Therefore, this client needs fluid resuscitation, not fluid restriction. A client with pancreatitis is most comfortable lying on the side with knees flexed.

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 -Preventing fluid volume overload -Maintaining adequate nutritional status -Teaching about the disease and its treatment

-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.

Acute Pancreatitis - Complications - WHY?

Tetany - D/t Hypocalcemia, which is d/t fat necrosis. Cardio - Shock. may occur in severe pancreatitis Acute Renal failure - may occur in severe pancreatitis Paralytic ileus - d/t inflammation and irritation of intraabdominal cavity. Coag (DIC) - rare but possible complication. Won't talk about in depth as it's very complex, and quite rare. Pathological process characterized by widespread activation of the clotting cascade that results in occlusion of small vessel and poor tissue perfusion first, then as clotting factors are used up, then widespread hemorrhage occurs. Thought that DIC is initiated as circulating pancreatic enzymes (trypsin!) cause damage throughout the body. Necrotizing Hemorrhage - d/t damage of and necrosis to pancreatic and abdominal vasculature as enzymes eat away and blood vessels and healthy tissue. Septic - DM - as the endocrine portion of the pancreas is inflamed and damaged. May require short-term insulin therapy; whereas, some may need antidiabetics for life. Each is a result of pancreatic enzymes wreaking havoc.

Acute Pancreatitis - Collab Care (Surgery)

Most pts c acute are treated medically rather than surgically. Surgery may be performed in anticipation of rupturing pseudocyst or when medical therapy ineffective. Extent of surgery varies c severity. Some may require debridement of necrotic tissue of and around the pancreas. Some may need more elaborate, WHIPPLE procedure, which involves resection or removal of the head of the pancreas, the bile duct, and the duodenum. - Most aggressive and extensive, which is more common c pancreatic cancer. All post-op implications applicable, c emphasis on skin care around incision and stoma (if there is one). Leaks may occur around surgical site ^ r/f irritation of skin around site. Stomahesive can be very helpful in protecting skin. If bowel diversion is placed d/t fistula development, strict I&O required and careful monitoring of electrolytes. Ostomies in high gi tract are associated c high watery effluence and will deplete electrolytes.

Chronic Pancreatitis - NOTES

- May follow acute pancreatitis - May occur in absence of any history of acute condition Same etiological factors - Laboratory tests * Serum amylase/lipse may be slightly ↑ or not at all * ↑ESR, alkaline phosphatase, bilirubin * Stool samples Dx generally the same. Same may have ^ liver enzymes and bili. Maybe increased ESR - typically accompanies pancreatitis c autoimmune disease or systemic inflamm conditions. Stool samples for bili byprods, and undigested fats.

Which condition is most likely to have a nursing diagnosis of fluid volume deficit? -Appendicitis -Pancreatitis -Cholecystitis -Gastric ulcer

-Pancreatitis Hypovolemic shock from fluid shifts is a major factor in acute pancreatitis. Appendicitis, cholecystitis, and gastric ulcer are less likely to exhibit fluid volume deficit.

Hypothyroidism - V constipation

30g of fiber/day.

Pancreatitis - Which labs need to be monitored for low levels?

Extremely important to monitor serum electrolyte levels. Pt may beexperience in all electrolytes as result of N/V. And dehydration. Calcium MUST be monitored, as it is present in fat necrosis.

Acute Pancreatitis - Which labs may be increased?

May have ^ liver enzymes, ^ triglycerides, ^ blood glucose d/t impaired insulin production, ^ bilirubin.

Hyperthyroidism - Tx

Radioactive Iodine Tx

Hyper - Labs

TSH V T3 & T4 ^ BMR ^

Acute Pancreatitis - Collab Care ( Alt. Fluid & Electrolytes)

In acute stages, pts should be kept NPO to reduce further stimulation of pancreatic enzymes. All pts should have IV access c large bore preferred (18g or larger) c continuous fluids to maintain hydration. Electrolytes monitors q day at minimum. There my be deficits in ALL.. CHECK HYPOKALEMIA (muscle cramping and weakness, along c cardiac dysrhythmias). All pts should be on cardiac monitoring for continuous assessment of HR and rhythm. MONITOR FOR HYPOCALCEMIA (hyperreflexia, overreactive DTRs, twitching and tremors, followed by tetany and seizures. Chvostek and Trousseu's signs. Decreases in other electrolytes (such as magnesium) may exacerbate cardiac symptoms. Aggressive parenteral replacement is indicated if electrolyte deficiencies are present. Calcium and magnesium gluconate, along c potassium chloride are preparations of choice.

Acute Pancreatitis - COMPLICATIONS

Pseudocyst and abscess. - potential local complications.. Pseudo - fluid filled, enzyme and exudate filled, capsule surrounded by a wall within the pancreas. May resolve on their own. Pseudo may rupture or perforate, causing more acute inflammation and peritonitis. Pseudocyst s/s: similar to s/s of pancreatitis itself. Adbominal pain, n/v, loss of appetite. May be palpable in epigastric area, but deep palpation may cause rupture. If not resolved on their own, may be drained in surgery or through a cath inserted in the skin. Abscess - Collection of puss, which often occurs from an infected or ruptured pseodocysts. Surgical emergency and will not resolve on their own. Surgery done to prevent contamination and infection of other organs. S/S very ^ WBC, ^fever, severe abdominal (worse than pancreatitis itself). Abscessed should be expected in pts dx c pancreatitis who acutely develop high temps, or have a sudden ^ in severity of pain. Pancreatitis may result development of several systemic complications. Overall, severity of the disease itself and any resulting complications is directly proportional the damage to the pancreas. Some pts may recover rapidly, c no complications and never experience another attack. Some may experience mild complications. Others may develop chronic. In some,, acute is devastating and life-threatening------ARDS (will learn in depth in 260). A result of vasodilation and increased vascular permeability effecting the lungs. Fluid moves into the pleural space, resulting in effusion and atelectasis. Fluid combined c ^s in intrapleural pressure, severely impairs gas exchange. Pts will demonstrate s/s of acute resp. distress and hypoxia. Most pts c ARDS require intubation and mechanical ventilation.

Pancreatitis - Acute Pain (additional interventions)

Anticholinergics to decrease vagal stimulation thus decrease enzyme production - must be avoided if pt has a paralytic ileus - Anticholinergics slow GI motility through smooth muscle relaxation... This will exacerbate and prolong ileus and may lead to bowel obstruction. We must auscultate bowel sounds!!!!!!!!!!!!! 5 mins total. If BS absent, anticholingergics should be held, and primary provider should be notified. Positions decrease intrabdominal pressure. HOB should always remain at 45 degrees or more. Knees to abdomen. Splinting techniques helpful. - especially important when encouraging pt to breathe deeply. Pain may inhibit lung expansion.

Acute pancreatitis - Enzymes

Trypsin: elastase, phospholipase A; lipase; kallikrein.

A nursing student has been assigned to care for a client with pancreatic cancer. The student is aware that the risk for pancreatic cancer is most directly proportional to -Age -Dietary intake of fat -Cigarette smoking -Presence of diabetes mellitus

-Age Incidence of pancreatic cancer increases with age, peaking in the seventh and eighth decades for both men and women. It is very rare before 45 years, and most patients present in or beyond the sixth decade of life. Cigarette smoking, exposure to industrial chemicals or toxins in the environment, and a diet high in fat, meat, or both are associated with pancreatic cancer, although their roles are not completely clear. Diabetes mellitus, chronic pancreatitis, and hereditary pancreatitis are also associated with pancreatic cancer.

Which condition in a client with pancreatitis makes it necessary for the nurse to check fluid intake and output, check hourly urine output, and monitor electrolyte levels? -Frequent vomiting, leading to loss of fluid volume -Dry mouth, which makes the client thirsty -Acetone in the urine -High glucose concentration in the blood

-Frequent vomiting, leading to loss of fluid volume Fluid and electrolyte disturbances are common complications because of nausea, vomiting, movement of fluid from the vascular compartment to the peritoneal cavity, diaphoresis, fever, and the use of gastric suction. The nurse assesses the client's fluid and electrolyte status by noting skin turgor and moistness of mucous membranes. The nurse weighs the client daily and carefully measures fluid intake and output, including urine output, nasogastric secretions, and diarrhea.

A patient is receiving pharmacologic therapy with ursodeoxycholic acid or chenodeoxy-cholic acid for treatment of small gallstones. The patient asks the nurse how long the therapy will take to dissolve the stones. What is the best answer the nurse can give?

6 to 12 months Explanation: Ursodeoxycholic acid (UDCA [Urso, Actigall]) and chenodeoxycholic acid (chenodiol or CDCA [Chenix]) have been used to dissolve small, radiolucent gallstones composed primarily of cholesterol (Karch, 2012). Six to 12 months of therapy is required in many patients to dissolve stones, and monitoring of the patient for recurrence of symptoms or the occurrence of side effects (e.g., GI symptoms, pruritus, headache) is required during this time.

The nurse admits a woman who is 8 weeks postpartum. The client presents with reports of severe right upper quadrant pain that radiates to her back. She states she just finished eating Thanksgiving dinner earlier that evening. The nurse suspects gallbladder disease. Statistics show that incidence of gallbladder disease is greater for women who are which of the following? Select all that apply.

Multiparous Obese Explanation: Two to three times more women than men develop cholesterol stones and gallbladder disease; affected women are usually older than 40 years, multiparous, and obese.

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 Explanation: 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.

The nurse is caring for a client with a biliary disorder who has an elevated amylase level. If this elevation correlates to dysfunction, which body process does the nurse recognize may be impaired? -Carbohydrate digestion -Protein synthesis -Fat digestion -Protein digestion

-Carbohydrate digestion Amylase is a pancreatic enzyme involved in the breakdown and digestion of carbohydrates. Trypsin aids in the digestion of proteins. Lipase aids in the digestion of fats.

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? -Increased serum calcium levels -Elevated urine amylase levels -Decreased liver enzyme levels -Decreased white blood cell count

-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.

A client is admitted to the health care center with severe abdominal pain rated 10 on a 1-to-10 scale, tachycardia, hypertension, and muscle spasms. The nurse immediately administers morphine sulfate 4 mg slow intravenous pyelogram (IVP), as ordered. The nurse plans for which goal after administration of this mediation? -To increase the client's pain threshold -To control muscle spasms -To control blood pressure -To diagnose the cause of abdominal pain

-To increase the client's pain threshold Morphine, fentanyl, and hydromorphone act by depressing the central nervous system, thereby increasing the client's pain threshold.

Acute Pancreatitis - Studies for inflam and pseudocyst

Abdominal xray, US, and CT may be useful in detecting inflammation, as well as for detecting pseudocyst and abscess

A nursing instructor is lecturing to a class about chronic pancreatitis. Which of the following does the instructor list as major causes?

Alcohol consumption and smoking Explanation: Alcohol consumption in Western societies and malnutrition worldwide are the major causes of chronic pancreatitis. Smoking is another factor in the development of chronic pancreatitis. Because heavy drinkers usually smoke, it is difficult to separate the effects of the alcohol abuse and smoking. Obesity is a form of malnutrition. Acute pancreatitis does not usually lead to chronic pancreatitis unless complications develop.

Acute Pancreatitis - something plus Resp. Function

Be alert of pseudocyst, abscess, and peritonitis Sepsis/septic shock. High fever, or sudden increase in severity in pain, accompanied in board-like rigid abdomen. ACT STAT! CALL MD!!!! May be a surgical emergency. Place high emphasis on respiratory hygiene. Incentive spirometry, HOB, cough deep breathe. - prevent atelectasis. Pain mgmt. needed for compliance c breathing interventions.

Pancreatitis - Maybe indicated for obstruction

ERCP may be indicated if obstruction of duct is suspected, but be aware that it is also a CAUSE of acute pancreatitis and may exacerbate.

Pancreas - Two main functions

Endocrine: release of insulin and glucagon from the beta and alpha cells respectively Exocrine: Secretion of enzymes which travel through the pancreatic duct to their site of activation in the small intestine (enzymes help breakdown fats, proteins, and CHO).

Which of the following would be most appropriate for a client who is experiencing biliary colic?

Ensure that the client rests. Explanation: 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.

Upon receiving the dinner tray for a client admitted with acute gallbladder inflammation, the nurse will question which of the following foods on the tray?

Hot roast beef sandwich with gravy Explanation: The diet immediately after an episode of acute cholecystitis is initially limited to low-fat liquids. Cooked fruits, rice or tapioca, lean meats, mashed potatoes, bread, and coffee or tea may be added as tolerated. The client should avoid fried foods such as fried chicken, because fatty foods may bring on an episode of cholecystitis.

A student nurse is preparing a plan of care for a client with chronic pancreatitis. What nursing diagnosis related to the care of a client with chronic pancreatitis is the priority?

Impaired nutrition: less than body requirements Explanation: While each diagnosis may be applicable to this client, the priority nursing diagnosis is impaired nutrition: less than body requirements. The physician, nurse, and dietitian emphasize to the client and family the importance of avoiding alcohol and foods that have produced abdominal pain and discomfort in the past. Oral food or fluid intake is not permitted during the acute phase

Acute Pancreatitis - Prevent/Identify/Treat infections

Infection is leading cause of death in pts c acute pancreatitis. Inflamed pancreas is an excellent medium for bacterial growth. All pts will have broad spectrum abx.

Which of the following conditions is most likely to involve a nursing diagnosis of fluid volume deficit?

Pancreatitis Explanation: Hypotension is typical and reflects hypovolemia and shock caused by the loss of large amounts of protein-rich fluid into the tissues and peritoneal cavity. The other conditions are less likely to exhibit fluid volume deficit.

Which condition is most likely to have a nursing diagnosis of fluid volume deficit?

Pancreatitis Explanation: Hypovolemic shock from fluid shifts is a major factor in acute pancreatitis. Appendicitis, cholecystitis, and gastric ulcer are less likely to exhibit fluid volume deficit.

Pigment Explanation: 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.

Abscess - S/S

very ^ WBC, ^fever, severe abdominal (worse than pancreatitis itself). Abscessed should be expected in pts dx c pancreatitis who acutely develop high temps, or have a sudden ^ in severity of pain.

The nurse knows that the serum amylase concentration returns to normal within which time frame? -12 hours -24 hours -36 hours -48 hours

-48 hours Serum amylase usually returns to normal within 48 to 72 hours.

Acute Pancreatitis - Lipase

Fat necrosis > Fat binds c calcium > Hypocalcemia.

Acute Pancreatitis - Elastase

Necrosis of blood vessels and ductal fibers > Hemorrhage.

A nurse is providing dietary instructions to a client with a history of pancreatitis. Which instruction is correct?

"Maintain a high-carbohydrate, low-fat diet." Explanation: A client with a history of pancreatitis should avoid foods and beverages that stimulate the pancreas, such as fatty foods, caffeine, and gas-forming foods; should avoid eating large meals; and should eat plenty of carbohydrates, which are easily metabolized. Therefore, the only correct instruction is to maintain a high-carbohydrate, low-fat diet. An increased sodium or fluid intake isn't necessary because chronic pancreatitis isn't associated with hyponatremia or fluid loss.

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 helps control fluid and electrolyte imbalance." -"The tube provides relief from nausea and vomiting." -"The tube allows the gastrointestinal tract to rest." -"The tube allows toxins to be removed."

-"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 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? -Placing the client in a semi-Fowler's position -Maintaining nothing-by-mouth (NPO) status -Administering morphine I.V. as ordered -Providing mouth care

-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.

Sixty to eighty percent of pancreatic tumors occur in the head of the pancreas. Tumors in this region obstruct the common bile duct. Which of the following clinical manifestations would indicate a common bile duct obstruction associated with a tumor in the head of the pancreas? Choose all that apply. -Clay-colored stools -Dark urine -Jaundice -Pruritis -Weight gain

-Clay-colored stools -Dark urine -Jaundice -Pruritis 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.

Which is a clinical manifestation of cholelithiasis? -Epigastric distress before a meal -Clay-colored stools -Abdominal pain in the upper left quadrant -Nonpalpable abdominal mass

-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 is preparing a client for surgery. During preoperative teaching, the client asks where is bile stored. The nurse knows that bile is stored in the: -Cystic duct -Duodenum -Gallbladder -Common bile duct

-Gallbladder The gallbladder functions as a storage depot for bile.

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? -Low-sodium, high-potassium, low-fat diet -High-carbohydrate, high-protein, low-fat diet -Low-carbohydrate, high-potassium diet -High-carbohydrate, low-protein, low-fat diet

-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.

A nurse is planning care for a client with acute pancreatitis. Which client outcome does the nurse assign as the highest priority? -Developing no acute complications from the pancreatitis -Maintaining normal respiratory function -Maintaining satisfactory pain control -Achieving adequate fluid and electrolyte balance

-Maintaining normal respiratory function Airway and breathing are always the priority assessment. Acute pancreatitis produces retroperitoneal edema, elevation of the diaphragm, pleural effusion, and inadequate lung ventilation. Intra-abdominal infection and labored breathing increase the body's metabolic demands, which further decreases pulmonary reserve and can lead to respiratory failure. Maintenance of adequate respiratory function is the priority goal. The other outcomes would also be appropriate for the patient.

A client with acute pancreatitis has been started on total parenteral nutrition (TPN). Which action should the nurse perform after administration of the TPN? -Auscultate the abdomen for bowel sounds every 4 hours -Measure abdominal girth every shift -Monitor for reports of nausea and vomiting -Measure blood glucose concentration every 4 to 6 hours

-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.

When caring for a client with acute pancreatitis, the nurse should use which comfort measure? -Administering an analgesic once per shift, as ordered, to prevent drug addiction -Positioning the client on the side with the knees flexed -Encouraging frequent visits from family and friends -Administering frequent oral feedings

-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.

A client with carcinoma of the head of the pancreas is scheduled for surgery. Which of the following should a nurse administer to the client before surgery? -Potassium -Vitamin K -Vitamin B -Oral bile acids

-Vitamin K Clients with carcinoma of the head of the pancreas typically require vitamin K before surgery to correct a prothrombin deficiency. Potassium would be given only if the client's serum potassium levels were low. Oral bile acids are not prescribed for a client with carcinoma of the head of the pancreas; they are given to dissolve gallstones. Vitamin B has no implications in the surgery.

Acute Pancreatitis - Interventions (Health Promotion)

Assessment of predisposing factors Early diagnosis/treatment of cholelithiasis Once pt has one bout, they are more likely to have recurrences. Lifestyle assessment - gallbladder disease, alcohol use, smoking. Complete abstinence of alcohol (and tobacco) is key factors in preventing future attacks.

Acute Pancreatitis - Preferred Dx study

CT c contrast is the best imaging for pancreatitis.

A client with calculi in the gallbladder is said to have

Cholelithiasis Explanation: Calculi, or gallstones, usually form in the gallbladder from the solid constituents of bile; they vary greatly in size, shape, and composition. Cholecystitis is acute inflammation of the gallbladder. Choledocholithiasis is a gallstone in the common bile duct. Choledochotomy is an incision into the common bile duct.

Chronic Pancreatitis - Definition

Continuous, prolonged inflammatory process and fibrosis of the pancreas - Pancreas becomes destroyed as it is replaced by fibrotic tissue - Strictures and calcifications may occur Etiologies similar to acute. Especially cholelithiasis and sphincter of odi thing. Autoimmune disease. Pancreatic cancer. Sometimes no identifiable cause - idiopathic chronic pancreatitis.

Acute Pancreatitis - Dx Studies

Dx is confirmed through correlation of pt hx, physical s/s, and blood work. Test specific to dx of pancreatitis are pancreatitis and serum lipase levels. Both measured in blood. ^ indicate damage to pancreas. Amylase rises first, and elevated can be detected for 24-72hrs. Other conditions can cause this. Lipase more specific, but rises more slowly. Tells us that there is acute pancreatic injury. Urine - Will be elevated as well.

Acute pancreatitis - Autodigestion

Elastase is activated by trypsin and causes elastic fibers of the bld vessels and ducts to dissolve. The necrosis of the bld vessels results in bleeding, ranging from minor blding to massive hemorrhage of pancreatic tissue. Another panc enzyme KALLIKREIN causes the release of vasoactive peptides that lead to vasodilation and Increased vascular permeability further compounding the hemorrhagic process. The massive destruction of bld vessels by necrosis may lead to generalized hemorrhage with bld escaping into the retroperitoneal space/tissues. The pt with hemorrhagic pancreatitis is critically ill..extensive pancreatic destruction and shock may lead to death. Death in pts with acute pancreatitis results from irreversible shock.

Acute Pancreatitis - Phospholipase A

Fat necrosis; Cell membrane disruption > Fat binds to calcium > Hypocalcemia

Which condition in a client with pancreatitis makes it necessary for the nurse to check fluid intake and output, check hourly urine output, and monitor electrolyte levels?

Frequent vomiting, leading to loss of fluid volume Explanation: Fluid and electrolyte disturbances are common complications because of nausea, vomiting, movement of fluid from the vascular compartment to the peritoneal cavity, diaphoresis, fever, and the use of gastric suction. The nurse assesses the client's fluid and electrolyte status by noting skin turgor and moistness of mucous membranes. The nurse weighs the client daily and carefully measures fluid intake and output, including urine output, nasogastric secretions, and diarrhea.

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

Serum lipase Explanation: In most cases, serum amylase and lipase levels are elevated within 24 hours of the onset of the symptoms. Serum amylase usually returns to normal within 48 to 72 hours, but serum lipase levels may remain elevated for a longer period, often 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 Explanation: 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.

Muscle twitching and finger numbness Explanation: Muscle twitching and finger numbness indicate hypocalcemia, a potential complication of acute pancreatitis. Calcium may be prescribed to prevent or treat tetany, which may result from calcium losses into retroperitoneal (peripancreatic) exudate. The other data indicate other complications of acute pancreatitis but are not indicators of electrolyte imbalance.

Pancreatitis notes.....

Pancreatitis may result development of several systemic complications. Overall, severity of the disease itself and any resulting complications is directly proportional the damage to the pancreas. Some pts may recover rapidly, c no complications and never experience another attack. Some may experience mild complications. Others may develop chronic. In some,, acute is devastating and life-threatening------ARDS (will learn in depth in 260). A result of vasodilation and increased vascular permeability effecting the lungs. Fluid moves into the pleural space, resulting in effusion and atelectasis. Fluid combined c ^s in intrapleural pressure, severely impairs gas exchange. Pts will demonstrate s/s of acute resp. distress and hypoxia. Most pts c ARDS require intubation and mechanical ventilation.

Acute Pancreatitis - Surgical therapy is indicated if and types of surgery

Presence of gallstones Uncertain diagnosis Unresponsive to conservative therapy Abscess, pseudocyst, or severe peritonitis Presence of gallstones Uncertain diagnosis Unresponsive to conservative therapy Abscess, pseudocyst, or severe peritonitis

Relieving abdominal pain Explanation: 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.

Hypo - Labs

TSH ^ T3 & T4 V BMR V

The patient has developed peritonitis. Explanation: Abdominal guarding is present. A rigid or boardlike abdomen may develop and is generally an ominous sign, usually indicating peritonitis (Privette et al., 2011).

Acute pancreatitis - Less common causes

Trauma (postsurgical, external blunt, diagnostic procedures) Viral infections - Hepatitis Penetrating duodenal ulcer resulting in peritonitis - Ulcer perforations Pancreatic obstructions Drug toxicities Idiopathic - S a known etiology

Pseudocyst - S/S

similar to s/s of pancreatitis itself. Adbominal pain, n/v, loss of appetite. May be palpable in epigastric area, but deep palpation may cause rupture. If not resolved on their own, may be drained in surgery or through a cath inserted in the skin.

Which is the most common report by clients with pancreatitis? -Tarry, black stools and dark urine -Increased and painful urination -Increased appetite and weight gain -Severe, radiating abdominal pain

-Severe, radiating abdominal pain Clients with pancreatitis most commonly report severe mid- to upper-abdominal pain, radiating to both sides and straight to the back. The client may describe the stools as being frothy and foul smelling, not black or tarry. The client's urine may be dark. The client will not experience increased or painful urination, increased appetite, or weight gain.

Acute Pancreatitis - Trypsin

Edema; necrosis; hemorrhage. Activates other enzymes.

Cholecystitis Pain

Gallbladder pain classically manifest in RUQ, and radiates to R scapula, and also described as colicky. Pain from gallbladder may be relieved by vomiting. Because pain is main s/s of both disease processes, it is very important for us to differentiate characteristics. Ultimately, this may help lead to more timely dx and proper tx.

Pancreatitis occurs when

Occurs when pancreatic enzymes spill into the pancreatic tissues, resulting in auto-digestion (pancreas is literally eating away at itself), causing inflammation. Mild edema to life threatening hemorrhage.

Acute Pancreatitis - What diet would you recommend and why?

Once not NPO, small frequent meals. High carb diet recommended as carbs are least stimulating to exocrine pancreas (carbs have lowest effect on pancreatic enzyme prod and release), in addition lean protein and fresh fruits and veggies recommended. Avoid foods that stimulate pancreatic enzymes (high fat foods, such as fried foods, high fat dairy like butter and mayonnaise, along c caffeine and alcohol. High sugar foods should be avoided d/t r/f hyperglycemia.. Nurse should assist pt in menu selection. Useful time to teach pt healthy selections.

To avoid inflammation of the pancreas Explanation: Pancreatic secretion is increased by food and fluid intake and may cause inflammation of the pancreas.

To reduce gastric and pancreatic secretions Explanation: Anticholinergic medications reduce gastric and pancreatic secretion.

Total parental nutrition (TPN) should be used cautiously in clients with pancreatitis because they

cannot tolerate a high glucose concentration. Explanation: Total parenteral nutrition (TPN) is used carefully in clients with pancreatitis because some clients cannot tolerate a high glucose concentration, even with insulin coverage. Intake of coffee increases the risk for gallbladder contraction, whereas high protein intake increases risk for hepatic encephalopathy in clients with cirrhosis. Clients with pancreatitis should not be given high-fat foods because they are difficult to digest.

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 -Placing the patient in the prone position -Perform chest physiotherapy -Suction the patient every 4 hours

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

A client with suspected biliary obstruction due to gallstones reports changes to the color of his stools. Which stool color does the nurse recognize as common to biliary obstruction? -Gray -Black -Red -Green

-Gray A gray-white stool color is common with a biliary obstruction because the stool is no longer colored with bile pigments.

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." Explanation: 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.

"This pain is caused from the gas used to inflate your abdominal area during surgery. Sitting upright in a chair, walking, or using a heating pad may ease the discomfort." Explanation: If pain occurs in the right shoulder or scapular area (from migration of the carbon dioxide used to insufflate the abdominal cavity during the procedure), the nurse may recommend using a heating pad for 15 to 20 minutes hourly, sitting up in a bed or chair, or walking.

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 is used in the diagnostic evaluation of acute pancreatitis." -"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." -"It can assess for ecchymosis in the body."

-"It can detect unhealthy tissues in the pancreas and assess for abscesses and pseudocysts." -"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." 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.

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? -1 to 2 -3 to 5 -6 to 12 -13 to 18

-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.

Ursodeoxycholic acid (UDCA) has been used to dissolve small, radiolucent gallstones. Which duration of therapy is required to dissolve the stones? -1 to 4 months -4 to 6 months -6 to 12 months -Over 1 year

-6 to 12 months Six to 12 months of therapy with UDCA is recommended in clients to dissolve the stones.

-6 to 12 months Ursodeoxycholic acid (UDCA [Urso, Actigall]) and chenodeoxycholic acid (chenodiol or CDCA [Chenix]) have been used to dissolve small, radiolucent gallstones composed primarily of cholesterol (Karch, 2012). Six to 12 months of therapy is required in many patients to dissolve stones, and monitoring of the patient for recurrence of symptoms or the occurrence of side effects (e.g., GI symptoms, pruritus, headache) is required during this time.

This example of cholesterol gallstones (left side of picture) is the result of decreased bile acid synthesis and increased cholesterol synthesis in the liver, which in turn, form stones. Cholesterol stones account for what percentage of cases of gallbladder disease in the United States? -15% -25% -60% -75%

-75% Cholesterol stones account for approximately 75% of cases of gallbladder disease in the United States.

A client is evaluated for severe pain in the right upper abdominal quadrant, which is accompanied by nausea and vomiting. The physician diagnoses acute cholecystitis and cholelithiasis. For this client, which nursing diagnosis takes top priority? -Acute pain related to biliary spasms -Deficient knowledge related to prevention of disease recurrence -Anxiety related to unknown outcome of hospitalization -Imbalanced nutrition: Less than body requirements related to biliary inflammation

-Acute pain related to biliary spasms The chief symptom of cholecystitis is abdominal pain or biliary colic. Typically, the pain is so severe that the client is restless and changes positions frequently to find relief. Therefore, the nursing diagnosis of Acute pain related to biliary spasms takes highest priority. Until the acute pain is relieved, the client can't learn about prevention, may continue to experience anxiety, and can't address nutritional concerns.

A nursing instructor is lecturing to a class about chronic pancreatitis. Which of the following does the instructor list as major causes? -Malnutrition and acute pancreatitis -Alcohol consumption and smoking -Alcohol consumption and acute pancreatitis -Acute pancreatitis and alcohol consumption

-Alcohol consumption and smoking Alcohol consumption in Western societies and malnutrition worldwide are the major causes of chronic pancreatitis. Smoking is another factor in the development of chronic pancreatitis. Because heavy drinkers usually smoke, it is difficult to separate the effects of the alcohol abuse and smoking. Obesity is a form of malnutrition. Acute pancreatitis does not usually lead to chronic pancreatitis unless complications develop.

Clinical manifestations of common bile duct obstruction include all of the following except: -Amber-colored urine -Clay-colored feces -Pruritus -Jaundice

-Amber-colored urine 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 symptoms may be acute or chronic. Epigastric distress, such as fullness, abdominal distention, and vague pain in the right upper quadrant of the abdomen, may occur. If it goes untreated jaundice and pruritus can occur.

A client who had developed jaundice 2 months earlier is brought to the ED after attending a party and developing excruciating pain that radiated over the abdomen and into the back. Upon assessment, which additional symptom would the nurse expect this client to have? -Hypertension -Bile-stained vomiting -Warm, dry skin -Weight loss

-Bile-stained vomiting Nausea and vomiting are common in acute pancreatitis. The emesis is usually gastric in origin but may also be bile stained. Fever, jaundice, mental confusion, and agitation may also occur.

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? (Select all that apply.) -Amber-colored urine -Clay-colored feces -Pruritus -Jaundice -Pain in the left upper abdominal quadrant

-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.

A 70-year-old client is admitted with acute pancreatitis. The nurse understands that the mortality rate associated with acute pancreatitis increases with advanced age and attributes this to which gerontologic consideration associated with the pancreas? -Decreases in the physiologic function of major organs -Increases in the bicarbonate output by the kidneys -Increases in the rate of pancreatic secretion -Development of local complications

-Decreases in the physiologic function of major organs Acute pancreatitis affects people of all ages, but the mortality rate associated with acute pancreatitis increases with advancing age. The pattern of complications changes with age. Younger clients tend to develop local complications; the incidence of multiple organ failure increases with age, possibly as a result of progressive decreases in physiologic function of major organs with increasing age.

A patient is diagnosed with mild acute pancreatitis. What does the nurse understand is characteristic of this disorder? -Edema and inflammation -Pleural effusion -Sepsis -Disseminated intravascular coagulopathy

-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.

Upon receiving the dinner tray for a client admitted with acute gallbladder inflammation, the nurse will question which of the following foods on the tray? -Hot roast beef sandwich with gravy -Mashed potatoes -White rice -Vanilla pudding

-Hot roast beef sandwich with gravy The diet immediately after an episode of acute cholecystitis is initially limited to low-fat liquids. Cooked fruits, rice or tapioca, lean meats, mashed potatoes, bread, and coffee or tea may be added as tolerated. The client should avoid fried foods such as fried chicken, because fatty foods may bring on an episode of cholecystitis.

Which condition is the major cause of morbidity and mortality in clients with acute pancreatitis? -Shock -Pancreatic necrosis -MODS -Tetany

-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.

The nurse is caring for a client with acute pancreatitis who is admitted to the intensive care unit to monitor for pulmonary complications. What is the nurse's understanding of the pathophysiology of pulmonary complications related to pancreatitis? -Pancreatitis can elevate the diaphragm and alter the breathing pattern. -Pancreatitis causes thickening of pulmonary secretions, impairing oxygenation. -Pancreatitis can atrophy the diaphragm and alter the breathing pattern. -Pancreatitis causes alterations to hemoglobin, impairing oxygenation.

-Pancreatitis can elevate the diaphragm and alter the breathing pattern. Aggressive pulmonary care is required for clients with acute pancreatitis. Pancreatitis can elevate the diaphragm and alter the breathing pattern of clients. Pancreatitis can cause retention of pulmonary secretions but does not thicken the secretions. Acute pancreatitis does not alter the hemoglobin.

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. -Encourage the client to deep breathe and cough. -Instruct the client on the proper use of an incentive spirometer. -Encourage the client to ambulate frequently.

-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.

Because clients with pancreatitis cannot tolerate high-glucose concentrations, total parental nutrition (TPN) should be used cautiously with them. Which of the following interventions has shown great promise in the prognosis of clients with severe acute pancreatitis? -Providing intensive insulin therapy -Allowiing a clear liquid diet during the acute phase -Administering oral analgesics around the clock -Maintaining a high-Fowler's position

-Providing intensive insulin therapy Intensive insulin therapy (continuous infusion) in the critically ill client has undergone much study and has shown promise in terms of positive client outcomes when compared with intermittent insulin dosing. Glycemic control with normal or near normal blood glucose levels improves client outcomes. Total parental nutrition (TPN) is used carefully in clients with pancreatitis because some clients cannot tolerate a high-glucose concentration, even with insulin coverage. Clients with pancreatitis should not be given high-fat foods because they are difficult to digest. The current recommendation for pain management in this population is parenteral opioids. The nurse should maintain the client in a semi-Fowler's position to reduce pressure on the diaphragm.

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 -Presence of blood in the client's stool and recent hypertension -Presence of easy bruising and bradycardia -Adventitious breath sounds and hypertension

-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.

-Reposition the client every 2 hours. Repositioning the client every 2 hours minimizes the risk of atelectasis in a client who is being treated for pancreatitis. The client should be instructed to cough every 2 hours to reduce atelectasis. Monitoring the pulse oximetry helps show changes in respiratory status and promote early intervention, but it would do little to minimize the risk of atelectasis. Withholding oral feedings limits the reflux of bile and duodenal contents into the pancreatic duct.

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? -Fibrosis and atrophy of the pancreatic gland -Calcification of the pancreatic duct, leading to its blockage -Self-digestion of the pancreas by its own proteolytic enzymes -Use of loop diuretics to increase the incidence of 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 comes to the ED with severe abdominal pain, nausea, and vomiting. The physician plans to rule out acute pancreatitis. The nurse would expect the diagnosis to be confirmed by an elevated result on which laboratory test? -Serum calcium -Serum bilirubin -Serum amylase -Serum potassium

-Serum amylase Serum amylase and lipase concentrations are used to make the diagnosis of acute pancreatitis. Serum amylase and lipase concentrations are elevated within 24 hours of the onset of symptoms. Serum amylase usually returns to normal within 48 to 72 hours, but the serum lipase concentration may remain elevated for a longer period, often days longer than amylase. Urinary amylase concentrations also become elevated and remain elevated longer than serum amylase concentrations.

A patient is diagnosed with gallstones in the bile ducts. What laboratory results should the nurse review? -Serum ammonia concentration of 90 mg/dL -Serum albumin concentration of 4.0 g/dL -Serum bilirubin level greater than 1.0 mg/dL -Serum globulin concentration of 2.0 g/dL

-Serum bilirubin level greater than 1.0 mg/dL

A client is diagnosed with gallstones in the bile ducts. The nurse knows to review the results of blood work for a -Serum ammonia concentration of 90 mg/dL -Serum albumin concentration of 4.0 g/dL -Serum bilirubin level greater than 1.0 mg/dL -Serum globulin concentration of 2.0 g/dL

-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 physician has written the following orders for a new client admitted with pancreatitis: bed rest, nothing by mouth (NPO), and administration of total parenteral nutrition (TPN) . Which does the nurse attribute as the reason for NPO status? -To drain the pancreatic bed -To aid opening up of pancreatic duct -To prevent the occurrence of fibrosis -To avoid inflammation of the pancreas

-To avoid inflammation of the pancreas Pancreatic secretion is increased by food and fluid intake and may cause inflammation of the pancreas.

The nurse is caring for a patient with acute pancreatitis. The patient has an order for an anticholinergic medication. The nurse explains that the patient will be receiving that medication for what reason? -To decrease metabolism -To depress the central nervous system and increase the pain threshold -To reduce gastric and pancreatic secretions -To relieve nausea and vomiting

-To reduce gastric and pancreatic secretions Anticholinergic medications reduce gastric and pancreatic secretion.

Acute pain related to biliary spasms Explanation: The chief symptom of cholecystitis is abdominal pain or biliary colic. Typically, the pain is so severe that the client is restless and changes positions frequently to find relief. Therefore, the nursing diagnosis of Acute pain related to biliary spasms takes highest priority. Until the acute pain is relieved, the client can't learn about prevention, may continue to experience anxiety, and can't address nutritional concerns.

Acute Pancreatitis - Pain manifestations

As pancreas becomes more edematous, it distends and irritates the nerves within the abdominal cavity. In some pts, pain may be d/t obstruction in one or more ducts of hepatobiliary system. Classic pattern is in L upper quadron, but some note in mid epigastric. Pain often relates to pt's back. Often pain starts abtruptly, and is characterized as severe, deep, piercing, and unrelenting. Eating makes pain worse, as well as lying flat. Unlike gallbladder pain, it is NOT relieved by vomiting.

Pancreatitis - Pulmonary Diagnostics

CXR should be done to assess pulm. status in presence of effusions and atelectasis

Acute Pancreatitis - Patho

Caused by inflammation of the pancreas: Inflamm is caused by auto-digestion of the pancreas - Injury to pancreatic cells Injury to pancreatic cells d/t activation - activation of pancreatic enzymes

Cullen's and Turner's

Caused by seeping of bloody exudate into the abdominal wall. Both signs of pancreatic hemorrhage and indicate severe acute pancreatitis and may be precursors to shock in some cases. Cullen's discoloration around periumbilical area. Turner's discoloration of the flank. May be similar to ecchymosis, deep bruising, or hematoma. Important to remember that these are not present in all cases.

Abscess - Description

Collection of puss, which often occurs from an infected or ruptured pseodocysts. Surgical emergency and will not resolve on their own. Surgery done to prevent contamination and infection of other organs.

Decreases in the physiologic function of major organs Explanation: Acute pancreatitis affects people of all ages, but the mortality rate associated with acute pancreatitis increases with advancing age. The pattern of complications changes with age. Younger clients tend to develop local complications; the incidence of multiple organ failure increases with age, possibly as a result of progressive decreases in physiologic function of major organs with increasing age.

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

Edema and inflammation Explanation: 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.

Acute Pancreatitis - Kallikrein

Edema; Vascular permeability; Smooth muscle concentration; Vasodilation > Shock. Can lead to acute resp. distress syndrome, shock, circulatory collapse, and death.

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 Explanation: 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.

Acute Pancreatitis - Nutritional Therapy

NPO status initially to reduce pancreatic secretion - Many will require NG tube to reduce vomiting and gastric distension, and prevent stomach ulceration from stasis gastric contents. Many will be on anti-acid therapiy, H2 inhib, or PPI. Antiemetics for N/V Frequent oral care (1-2 hrs) should be implemented in NPO pts to relief dryness of oral mucosa, which can be exacerbated if the pt is on O2 therapy. Diligent oral care needed to prevent inflammation & breakdown of delicate tissue in oropharynx. Moistened mouth swabs and moistened mouth preps.... Can give to assistive personnel. Some pts c pancreatitis may need extended NPO period especially if attack is more severe or accompanied by paralytic ileus. TPN may be needed. MD will check by things such as total protein and albumin levels.

Pancreatitis - Acute Pain management

Pain is SEVERE. IV med therapy is therapy is choice: IV diladed (hydromorphone IVP). Morphine also possible, but morphine may cause spasm of sphincter of odi, which is located at the junction of the duodenum and common bile duct. Spasm may ^ pain, and if prolonged may exacerbate the pancreatitis. If morphine is used, it should be given c antispasmodic or anticholinergic med.

Providing intensive insulin therapy Explanation: Intensive insulin therapy (continuous infusion) in the critically ill client has undergone much study and has shown promise in terms of positive client outcomes when compared with intermittent insulin dosing. Glycemic control with normal or near normal blood glucose levels improves client outcomes. Total parental nutrition (TPN) is used carefully in clients with pancreatitis because some clients cannot tolerate a high-glucose concentration, even with insulin coverage. Clients with pancreatitis should not be given high-fat foods because they are difficult to digest. The current recommendation for pain management in this population is parenteral opioids. The nurse should maintain the client in a semi-Fowler's position to reduce pressure on the diaphragm.

Recent weight loss and temperature elevation Explanation: 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 client being treated for pancreatitis faces the risk of atelectasis. Which of the following interventions would be important to implement to minimize this risk?

Reposition the client every 2 hours. Explanation: Repositioning the client every 2 hours minimizes the risk of atelectasis in a client who is being treated for pancreatitis. The client should be instructed to cough every 2 hours to reduce atelectasis. Monitoring the pulse oximetry helps show changes in respiratory status and promote early intervention, but it would do little to minimize the risk of atelectasis. Withholding oral feedings limits the reflux of bile and duodenal contents into the pancreatic duct.

Self-digestion of the pancreas by its own proteolytic enzymes Explanation: 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.

Serum amylase Explanation: Serum amylase and lipase concentrations are used to make the diagnosis of acute pancreatitis. Serum amylase and lipase concentrations are elevated within 24 hours of the onset of symptoms. Serum amylase usually returns to normal within 48 to 72 hours, but the serum lipase concentration may remain elevated for a longer period, often days longer than amylase. Urinary amylase concentrations also become elevated and remain elevated longer than serum amylase concentrations.

Pancreatitis - Assess and tx of Shock

Uncommon, but remains a constant threat d/t vasoactive enzymes circulating in pts bloodstream (mainly kalikrieans). Goal: to maintain organ perfusion, mainly renal and cerebral, if shock is present. S/S: pts will demonstrate low bp, narrowed pulse pressure, tachypnea, reduced urine output, and skin may appear pale and cool. These pts may need fluids to increase intravascular volume and maintain oncotic pressure (dextran or albumin). In some pts, traditional crystalloid fluids are adequate. Monitor Serum Albumin. If htn present, pt may need dopamine or norepi to counteract systemic vasodilation.

Acute pancreatitis - Most common causes

gallbladder disease, and chronic alcohol use/abuse. Inflam of gallbladder, presence of stones (cholelethiasis), and buildup of thick, sludgy bile (biliary sludge, or microlethiasis), can contribute to episodes of acute pancreatitis d/t the reflux of bile into the pancreatic ducts, as well as d/t obstructions from small cholesterol and calcium salt deposits. In alcohol use, link not as well understood. Current data - chronic alcohol intake stimulates excess pancreatic enzymes > inflammation and auto-digestion. Smoking - Higher rate of tobacco use among those who abuse alcohol.

A nurse is providing dietary instructions to a client with a history of pancreatitis. Which instruction is correct? -"Maintain a high-fat diet and drink at least 3 L of fluid a day." -"Maintain a high-sodium, high-calorie diet." "Maintain a high-carbohydrate, low-fat diet." -"Maintain a high-fat, high-carbohydrate diet."

"Maintain a high-carbohydrate, low-fat diet." A client with a history of pancreatitis should avoid foods and beverages that stimulate the pancreas, such as fatty foods, caffeine, and gas-forming foods; should avoid eating large meals; and should eat plenty of carbohydrates, which are easily metabolized. Therefore, the only correct instruction is to maintain a high-carbohydrate, low-fat diet. An increased sodium or fluid intake isn't necessary because chronic pancreatitis isn't associated with hyponatremia or fluid loss.

A client discharged after a laparoscopic cholecystectomy calls the surgeon's office reporting severe right shoulder pain 24 hours after surgery. Which statement is the correct information for the nurse to provide to this client? -"This pain is caused from the gas used to inflate your abdominal area during surgery. Sitting upright in a chair, walking, or using a heating pad may ease the discomfort." -"This pain is caused from your incision. Take analgesics as needed and as prescribed and report to the surgeon if pain is unrelieved even with analgesic use." -"This may be the initial symptoms of an infection. You need to come to see the surgeon today for an evaluation." -"This pain may be caused by a bile duct injury. You will need to go to the hospital immediately to have this evaluated."

-"This pain is caused from the gas used to inflate your abdominal area during surgery. Sitting upright in a chair, walking, or using a heating pad may ease the discomfort." If pain occurs in the right shoulder or scapular area (from migration of the carbon dioxide used to insufflate the abdominal cavity during the procedure), the nurse may recommend using a heating pad for 15 to 20 minutes hourly, sitting up in a bed or chair, or walking.

A client with calculi in the gallbladder is said to have -Cholecystitis -Cholelithiasis -Choledocholithiasis -Choledochotomy

-Cholelithiasis Calculi, or gallstones, usually form in the gallbladder from the solid constituents of bile; they vary greatly in size, shape, and composition. Cholecystitis is acute inflammation of the gallbladder. Choledocholithiasis is a gallstone in the common bile duct. Choledochotomy is an incision into the common bile duct.

Increased appetite and thirst may indicate that a client with chronic pancreatitis has developed diabetes melitus. Which of the following explains the cause of this secondary diabetes? -Dysfunction of the pancreatic islet cells -Ingestion of foods high in sugar -Inability for the liver to reabsorb serum glucose -Renal failure

-Dysfunction of the pancreatic islet cells Diabetes mellitus resulting from dysfunction of the pancreatic islet cells is treated with diet, insulin, or oral antidiabetic agents. The hazard of severe hypoglycemia with alcohol consumption is stressed to the client and family. When secondary diabetes develops in a client with chronic pancreatitis, the client experiences increased appetite, thirst, and urination. A standard treatment with pancreatitis is to make the client NPO. The dysfunction is related to the pancreas, not the liver.

A student nurse is preparing a plan of care for a client with chronic pancreatitis. What nursing diagnosis related to the care of a client with chronic pancreatitis is the priority? -Disturbed body image -Impaired nutrition: less than body requirements -Nausea -Anxiety

-Impaired nutrition: less than body requirements While each diagnosis may be applicable to this client, the priority nursing diagnosis is impaired nutrition: less than body requirements. The physician, nurse, and dietitian emphasize to the client and family the importance of avoiding alcohol and foods that have produced abdominal pain and discomfort in the past. Oral food or fluid intake is not permitted during the acute phase.

A nurse is providing preoperative teaching to a client undergoing a cholecystectomy. Which topic should the nurse include in her teaching plan? -Increase respiratory effectiveness. -Eliminate the need for nasogastric intubation. -Improve nutritional status during recovery. -Decrease the amount of postoperative analgesia needed.

-Increase respiratory effectiveness. The nurse must teach the client about using an incentive spirometer to promote lung expansion. The high abdominal incision used in a cholecystectomy interferes with respirations postoperatively, increasing the risk of atelectasis. The client will need to use incentive spirometry to promote lung expansion, increase alveolar inflation, and strengthen respiratory muscles. Most clients don't have a nasogastric tube in place after a cholecystectomy. It isn't appropriate to teach improved nutritional status before surgery. It isn't important for the client to be aware of how to decrease the amount of postoperative analgesia, because this is the responsibility of the health care team.

Which of the following conditions is most likely to involve a nursing diagnosis of fluid volume deficit? -Appendicitis -Pancreatitis -Cholecystitis -Peptic ulcer

-Pancreatitis Hypotension is typical and reflects hypovolemia and shock caused by the loss of large amounts of protein-rich fluid into the tissues and peritoneal cavity. The other conditions are less likely to exhibit fluid volume deficit.

A patient with acute pancreatitis puts the call bell on to tell the nurse about an increase in pain. The nurse observes the patient guarding; the abdomen is boardlike and no bowel sounds are detected. What is the major concern for this patient? -The patient requires more pain medication. -The patient is developing a paralytic ileus. -The patient has developed peritonitis. -The patient has developed renal failure.

-The patient has developed peritonitis. Abdominal guarding is present. A rigid or boardlike abdomen may develop and is generally an ominous sign, usually indicating peritonitis (Privette et al., 2011).

The digestion of carbohydrates is aided by -lipase. -amylase. -trypsin. -secretin.

-amylase. Amylase is secreted by the exocrine pancreas. Lipase aids in the digestion of fats. Trypsin aids in the digestion of proteins. Secretin is the major stimulus for increased bicarbonate secretion from the pancreas.

Total parental nutrition (TPN) should be used cautiously in clients with pancreatitis because they -are at risk for gallbladder contraction. -are at risk for hepatic encephalopathy. -can digest high-fat foods. -cannot tolerate a high glucose concentration.

-cannot tolerate a high glucose concentration. Total parenteral nutrition (TPN) is used carefully in clients with pancreatitis because some clients cannot tolerate a high glucose concentration, even with insulin coverage. Intake of coffee increases the risk for gallbladder contraction, whereas high protein intake increases risk for hepatic encephalopathy in clients with cirrhosis. Clients with pancreatitis should not be given high-fat foods because they are difficult to digest.

A client with cholelithiasis has a gallstone lodged in the common bile duct. When assessing this client, the nurse expects to note: -yellow sclerae. -light amber urine. -circumoral pallor. -black, tarry stools.

-yellow sclerae. Yellow sclerae are an early sign of jaundice, which occurs when the common bile duct is obstructed. Urine normally is light amber. Circumoral pallor and black, tarry stools don't occur in common bile duct obstruction; they are signs of hypoxia and GI bleeding, respectively.

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 Explanation: 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.

Bile-stained vomiting Explanation: Nausea and vomiting are common in acute pancreatitis. The emesis is usually gastric in origin but may also be bile stained. Fever, jaundice, mental confusion, and agitation may also occur.

Which is a clinical manifestation of cholelithiasis?

Clay-colored stools Explanation: 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.

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

Deficient fluid volume Explanation: 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 planning care for a client with acute pancreatitis. Which client outcome does the nurse assign as the highest priority?

Maintaining normal respiratory function Explanation: Airway and breathing are always the priority assessment. Acute pancreatitis produces retroperitoneal edema, elevation of the diaphragm, pleural effusion, and inadequate lung ventilation. Intra-abdominal infection and labored breathing increase the body's metabolic demands, which further decreases pulmonary reserve and can lead to respiratory failure. Maintenance of adequate respiratory function is the priority goal. The other outcomes would also be appropriate for the patient.

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 Explanation: 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.

A client with carcinoma of the head of the pancreas is scheduled for surgery. Which of the following should a nurse administer to the client before surgery?

Vitamin K Explanation: Clients with carcinoma of the head of the pancreas typically require vitamin K before surgery to correct a prothrombin deficiency. Potassium would be given only if the client's serum potassium levels were low. Oral bile acids are not prescribed for a client with carcinoma of the head of the pancreas; they are given to dissolve gallstones. Vitamin B has no implications in the surgery.

Which is the most common report by clients with pancreatitis?

Severe, radiating abdominal pain Explanation: Clients with pancreatitis most commonly report severe mid- to upper-abdominal pain, radiating to both sides and straight to the back. The client may describe the stools as being frothy and foul smelling, not black or tarry. The client's urine may be dark. The client will not experience increased or painful urination, increased appetite, or weight gain.

Which foods should be avoided following acute gallbladder inflammation?

Cheese Explanation: The client should avoid eggs, cream, pork, fried foods, cheese, rich dressings, gas-forming vegetables, and alcohol. It is important to remind the client that fatty foods may induce an episode of cholecystitis. Cooked fruits, rice or tapioca, lean meats, mashed potatoes, non-gas-forming vegetables, bread, coffee, or tea may be consumed as tolerated.

A client who is 24 hours post op from laparoscopic cholecystectomy calls the nurse and reports pain in the right shoulder. How should the nurse respond to the client's report of symptoms? -"Apply a heating pad to your shoulder for 15 minutes hourly as needed." -"Come into the emergency room as soon as possible." -"Take an over the counter analgesic as needed." -"Place your shoulder in a sling to avoid moving it."

-"Apply a heating pad to your shoulder for 15 minutes hourly as needed." Pain in the right shoulder may occur after laparoscopic cholecystectomy due to migration of the carbon dioxide used to insufflate the abdominal cavity during the procedure. The nurse should instruct the client to apply a heating pad to the shoulder for 15 to 20 minutes every hour as needed for pain relief. The nurse should not instruct the client to take analgesic medication-this is a medical order performed by the health care provider only. This scenario is not life threatening and the client does not need to go to the emergency department. It is also not necessary for the client to place the shoulder in a sling as this is not an injury-related condition.

A client with carcinoma of the head of the pancreas is scheduled for surgery. Which of the following should the nurse administer to the client before surgery? -Packed red blood cells -Vitamin C -Potassium -Oral bile acids

-Packed red blood cells Preoperative preparation includes adequate hydration, correction of prothrombin deficiency with vitamin K, and treatment of anemia to minimize postoperative complications. Parenteral nutrition and blood component therapy are frequently required. Potassium would be given only if the client's serum potassium levels were low. Oral bile acids are not prescribed for a client with carcinoma of the head of the pancreas; they are given to dissolve gallstones. Vitamin C has no implications in the surgery.

A very ill client with acute cholecystitis is scheduled for surgery. The surgeon plans to create an incision in the common bile duct to remove stones. The nurse correctly documents this surgery in the electronic medical record using which term?

Choledochostomy Explanation: This procedure is reserved for the client with acute cholecystitis who may be too ill to undergo a surgical procedure. It involves making an incision in the common duct, usually to remove stones (choledochostomy).

Clay-colored stools Dark urine Jaundice Pruritis Explanation: 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 nurse is preparing a client for surgery. During preoperative teaching, the client asks where is bile stored. The nurse knows that bile is stored in the:

Gallbladder Explanation: The gallbladder functions as a storage depot for bile

A client with cholelithiasis has a gallstone lodged in the common bile duct. When assessing this client, the nurse expects to note:

yellow sclerae. Explanation: Yellow sclerae are an early sign of jaundice, which occurs when the common bile duct is obstructed. Urine normally is light amber. Circumoral pallor and black, tarry stools don't occur in common bile duct obstruction; they are signs of hypoxia and GI bleeding, respectively.

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