Chapter 47: Caring for Clients with Disorders of the Liver, Gallbladder, or Pancreas

The family of a client in the ICU diagnosed with acute pancreatitis asks the nurse why the client has been moved to an air bed. What would be the nurse's best response?

"The bed automatically moves, so she's less likely to develop pressure sores while she's in bed." Explanation: It is important to turn the client every 2 hours; use of specialty beds may be indicated to prevent skin breakdown. The rationale for a specialty bed is not related to repositioning, comfort, or ease of movement.

An important message for any nurse to communicate is that drug-induced hepatitis is a major cause of acute liver failure. The medication that is the leading cause is:

Acetaminophen Explanation: Although any medication can affect liver function, use of acetaminophen (found in many over-the-counter medications used to treat fever and pain) has been identified as the leading cause of acute liver failure. Other medications commonly associated with liver injury include anesthetic agents, medications used to treat rheumatic and musculoskeletal disease, antidepressants, psychotropic medications, anticonvulsants, and antituberculosis agents

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 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.

A client is being treated for acute pain from an episode of pancreatitis. The nurse has identified a nursing diagnosis of Ineffective Breathing Pattern related to pain secondary to effects of surgery. Which intervention should the nurse perform in order to best address this diagnosis? You

Administer analgesic per orders. Explanation: The client has ineffective breathing patterns due to pain. To increase the likelihood of the client being able to perform interventions for his/her respiratory status, it would be important to treat acute pain first. A supine position will result in increased pressure on the diaphragm and potentially decreased respiratory expansion. Steroids and oral suctioning are not indicated

A nurse is amending a client's plan of care in light of the fact that the client has recently developed ascites. What should the nurse include in this client's care plan?

Administration of diuretics as prescribed Explanation: Use of diuretics along with sodium restriction is successful in 90% of clients with ascites. Beta-blockers are not used to treat ascites and bed rest is often more beneficial than increased mobility. Vitamin B12 injections are not necessary.

A nurse is teaching a client about the types of chronic liver disease. The teaching is determined to be effective when the client correctly identifies which type of cirrhosis as being caused by scar tissue surrounding portal areas?

Alcoholic cirrhosis Explanation: Alcoholic cirrhosis, in which the scar tissue characteristically surrounds the portal areas, is most frequently caused by chronic alcoholism and is the most common type of cirrhosis. In postnecrotic cirrhosis, there are broad bands of scar tissue, which are a late result of a previous acute viral hepatitis. In biliary cirrhosis, scarring occurs in the liver around the bile ducts. Compensated cirrhosis is a general term given to the state of liver disease in which the liver continues to be able to function effectively.

Lactulose (Cephulac) is administered to a patient diagnosed with hepatic encephalopathy to reduce which of the following?

Ammonia Explanation: Lactulose (Cephulac) is administered to reduce serum ammonia levels. Cephulac does not influence calcium, bicarbonate, or alcohol levels.

The nurse is caring for a patient with cirrhosis of the liver and observes that the patient is having hand-flapping tremors. What does the nurse document this finding as?

Asterixis Explanation: Asterixis, an involuntary flapping of the hands, may be seen in stage II encephalopathy (Fig. 49-13

A nurse is caring for a client with hepatic encephalopathy. While making the initial shift assessment, the nurse notes that the client has a flapping tremor of the hands. The nurse should document the presence of what sign of liver disease?

Asterixis Explanation: The nurse will document that a client exhibiting a flapping tremor of the hands is demonstrating asterixis. While constructional apraxia is a motor disturbance, it is the inability to reproduce a simple figure. Fetor hepaticus is a sweet, slightly fecal odor to the breath and not associated with a motor disturbance. Skin changes associated with liver dysfunction may include palmar erythema, which is a reddening of the palms, but is not a flapping tremor

A nurse is caring for a client with hepatic encephalopathy. While making the initial shift assessment, the nurse notes that the client has a flapping tremor of the hands. The nurse should document the presence of what sign of liver disease

Asterixis Explanation: The nurse will document that a client exhibiting a flapping tremor of the hands is demonstrating asterixis. While constructional apraxia is a motor disturbance, it is the inability to reproduce a simple figure. Fetor hepaticus is a sweet, slightly fecal odor to the breath and not associated with a motor disturbance. Skin changes associated with liver dysfunction may include palmar erythema, which is a reddening of the palms, but is not a flapping tremor.

A client returns to the floor after a laparoscopic cholecystectomy. The nurse should assess the client for signs and symptoms of what serious potential complication of this surgery?

Bile duct injury Explanation: The most serious complication after laparoscopic cholecystectomy is a bile duct injury. Clients do not face a risk of diabetic coma. A decubitus ulcer is unlikely because immobility is not expected. Evisceration is highly unlikely, due to the laparoscopic approach.

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.

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 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 55-year-old female client with hepatocellular carcinoma (HCC) is undergoing radiofrequency ablation. The nurse should recognize what goal of this treatment?

Destruction of the client's liver tumor Explanation: Using radiofrequency ablation, a tumor up to 5 cm in size can be destroyed in one treatment session. This technique does not address circulatory function or abscess formation. It does not allow for the reversal of metastasis.

A group of nurses have attended an in-service on the prevention of occupationally acquired diseases that affect health care providers. What action has the greatest potential to reduce a nurse's risk of acquiring hepatitis C in the workplace?

Disposing of sharps appropriately and not recapping needles Explanation: HCV is bloodborne. Consequently, prevention of needlestick injuries is paramount. Hand hygiene, immunizations and appropriate use of masks are important aspects of overall infection control, but these actions do not directly mitigate the risk of HCV.

A nurse has admitted a client suspected of having acute pancreatitis. The nurse knows that mild acute pancreatitis is characterized by

Edema and inflammation Explanation: Severe abdominal pain is the major symptom of pancreatitis that causes the client to seek medical care. Abdominal pain and tenderness and back pain result from irritation and edema of the inflamed pancreas.

During a health education session, a participant has asked about the hepatitis E virus. What prevention measure should the nurse recommend for preventing infection with this virus?

Following proper hand-washing techniques Explanation: Avoiding contact with the hepatitis E virus through good hygiene, including hand-washing, is the major method of prevention. Hepatitis E is transmitted by the fecal-oral route, principally through contaminated water in areas with poor sanitation. Consequently, none of the other listed preventative measures is indicated.

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

A client and spouse are visiting the clinic. The client recently experienced a seizure and says she has been having difficulty writing. Before the seizure, the client says that for several weeks she was sleeping late into the day but having restlessness and insomnia at night. The client's husband says that he has noticed the client has been moody and slightly confused. Which of the following problems is most consistent with the client's clinical manifestations

Hepatic encephalopathy Explanation: The earliest symptoms of hepatic encephalopathy include minor mental changes and motor disturbances. The client appears slightly confused and unkempt and has alterations in mood and sleep patterns. The client tends to sleep during the day and have restlessness and insomnia at night. As hepatic encephalopathy progresses, the client may become difficult to awaken and completely disoriented with respect to time and place. With further progression, the client lapses into frank coma and may have seizures. Simple tasks, such as handwriting, become difficult

A nurse is caring for a client with liver failure and is performing an assessment of the client's increased risk of bleeding. The nurse recognizes that this risk is related to the client's inability to synthesize prothrombin in the liver. What factor most likely contributes to this loss of function?

Inability of the liver to use vitamin K Explanation: Decreased production of several clotting factors may be partially due to deficient absorption of vitamin K from the GI tract. This probably is caused by the inability of liver cells to use vitamin K to make prothrombin. This bleeding risk is unrelated to the roles of glucose, bile salts, or albumin

A client with a cholelithiasis has been scheduled for a laparoscopic cholecystectomy. Why is laparoscopic cholecystectomy preferred by surgeons over an open procedure?

Laparoscopic cholecystectomy poses fewer surgical risks than an open procedure. Explanation: Open surgery has largely been replaced by laparoscopic cholecystectomy (removal of the gallbladder through a small incision through the umbilicus). As a result, surgical risks have decreased, along with the length of hospital stay and the long recovery period required after standard surgical cholecystectomy. Both approaches allow for removal of the entire gallbladder and must be performed under general anesthesia in an operating theater.

Which enzyme aids in the digestion of fats?

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

A physician orders spironolactone (Aldactone), 50 mg by mouth four times daily, for a client with fluid retention caused by cirrhosis. Which finding indicates that the drug is producing a therapeutic effect?

Loss of 2.2 lb (1 kg) in 24 hours Explanation: Daily weight measurement is the most accurate indicator of fluid status; a loss of 2.2 lb (1 kg) indicates loss of 1 L of fluid. Because spironolactone is a diuretic, weight loss is the best indicator of its effectiveness. This client's serum potassium and sodium levels are normal. A blood pH of 7.25 indicates acidosis, an adverse reaction to spironolactone

A critically ill client is diagnosed with acute liver failure caused by an overdose of acetaminophen. Which treatment will the nurse anticipate being prescribed for the client?

N-acetylcysteine Explanation: Acute hepatic failure or acute liver failure (ALF) is the clinical syndrome of sudden and severely impaired liver function in a person who was previously healthy. Supporting the client in the ICU and assessing the indications for and feasibility of liver transplantation are hallmarks of management. The use of antidotes for certain conditions may be indicated, such as N-acetylcysteine for acetaminophen toxicity. Penicillin is used for mushroom poisoning. Prostaglandins are used to enhance hepatic blood flow. Plasma exchange is used to correct coagulopathy, reduce serum ammonia levels, and stabilize the client awaiting liver transplantation.

Which is the most common cause of esophageal varices?

Portal hypertension Explanation: Esophageal varices are almost always caused by portal hypertension, which results from obstruction of the portal circulation within the damaged liver. Jaundice occurs when the bilirubin concentration in the blood is abnormally elevated. Ascites results from circulatory changes within the diseased liver. Asterixis is an involuntary flapping movement of the hands associated with metabolic liver dysfunction.

The nurse is caring for a client with cirrhosis. Which assessment findings indicate that the client has deficient vitamin K absorption caused by this hepatic disease?

Purpura and petechiae Explanation: A hepatic disorder, such as cirrhosis, may disrupt the liver's normal use of vitamin K to produce prothrombin (a clotting factor). Consequently, the nurse should monitor the client for signs of bleeding, including purpura and petechiae. Dyspnea and fatigue suggest anemia. Ascites and orthopnea are unrelated to vitamin K absorption. Gynecomastia and testicular atrophy result from decreased estrogen metabolism by the diseased liver.

A nurse is caring for a client with cirrhosis secondary to heavy alcohol use. The nurse's most recent assessment reveals subtle changes in the client's cognition and behavior. What is the nurse's most appropriate response?

Report this finding to the primary provider due to the possibility of hepatic encephalopathy. Explanation: Monitoring is an essential nursing function to identify early deterioration in mental status. The nurse monitors the client's mental status closely and reports changes so that treatment of encephalopathy can be initiated promptly. This change in status is likely unrelated to sodium intake and would not signal the onset of hepatitis. A supportive care environment is beneficial, but does not address the client's physiologic deterioration

A client is demonstrating symptoms of pancreatic cancer. Which diagnostic test will the nurse expect to be prescribed to prepare the client for surgery?

Spiral computed tomography (CT) scan Explanation: Spiral (helical) computed tomography (CT) is more than 85% to 90% accurate in the diagnosis and staging of pancreatic cancer and currently is the most useful preoperative imaging technique. Endoscopic ultrasound is useful to identify small tumors and perform fine-needle biopsy of primary tumors or lymph nodes. Percutaneous transhepatic cholangiography may be used to identify obstructions of the biliary tract by a pancreatic tumor. Endoscopic retrograde cholangiopancreatogram (ERCP) may also be used in the diagnosis of pancreatic carcinoma. Cells obtained during ERCP are sent to the laboratory for analysis.

The nurse is concerned about potassium loss when a diuretic is prescribed for a patient with ascites and edema. What diuretic may be ordered that spares potassium and prevents hypokalemia?

Spironolactone (Aldactone) Explanation: Potassium-sparing diuretic agents such as spironolactone or triamterene (Dyrenium) may be indicated to decrease ascites, if present; these diuretics are preferred because they minimize the fluid and electrolyte changes commonly seen with other agents.

During chronic pancreatitis, the patient's stool may become frothy and foul-smelling. This would be documented as which of the following?

Steatorrhea Explanation: The stool becomes frequent, frothy, and foul-smelling because of impaired fat digestion, which results in stools with a high fat content.

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

Which medication is used to decrease portal pressure, halting bleeding of esophageal varices?

Vasopressin Explanation: Vasopressin may be the initial therapy for esophageal varices because it produces constriction of the splanchnic arterial bed and decreases portal hypertension. Nitroglycerin has been used to prevent the side effects of vasopressin. Spironolactone and cimetidine do not decrease portal hypertension.

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

A client has just been diagnosed with hepatitis A. On assessment, the nurse expects to note:

anorexia, nausea, and vomiting. Explanation: Early hallmark signs and symptoms of hepatitis A include anorexia, nausea, vomiting, fatigue, and weakness. Abdominal pain may occur but doesn't radiate to the shoulder. Eructation and constipation are common in gallbladder disease, not hepatitis A. Abdominal ascites is a sign of advanced hepatic disease, not an early sign of hepatitis A

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

cannot tolerate high-glucose concentration. Explanation: Total parental 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 intake of high protein increases risk for hepatic encephalopathy in clients with cirrhosis. Patients with pancreatitis should not be given high-fat foods because they are difficult to digest.

A client is admitted for suspected GI disease. Assessment data reveal muscle wasting, a decrease in chest and axillary hair, and increased bleeding tendency. The nurse suspects the client has:

cirrhosis. Explanation: Muscle wasting, a decrease in chest and axillary hair, and increased bleeding tendencies are all symptoms of cirrhosis. The client may also have mild fever, edema, abdominal pain, and an enlarged liver. Clients with peptic ulcer disease complain of a dull, gnawing epigastric pain that's relieved by eating. Appendicitis is characterized by a periumbilical pain that moves to the right lower quadrant and rebound tenderness. Cholelithiasis is characterized by severe abdominal pain that presents several hours after a large meal

What is the recommended dietary treatment for a client with chronic cholecystitis?

low-fat diet Explanation: The bile secreted from the gallbladder helps the body absorb and break down dietary fats. If the gallbladder is not functioning properly, then it will not secrete enough bile to help digest the dietary fat. This can lead to further complications; therefore, a diet low in fat can be used to prevent complications.

A nurse educator is providing an in-service to a group of nurses working on a medical floor that specializes in liver disorders. What is an important education topic regarding ingestion of medications?

metabolism of medications Explanation: Careful evaluation of the client's response to drug therapy is important because the malfunctioning liver cannot metabolize many substances.

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

yellow sclerae.