Transcript BILIARY CONDITIONS

Biliary Conditions
NUR-224
OBJECTIVES
• Discus management of patient with
cholelithiasis.
• Use the nursing process a framework for care of
–patients with cholelithiasis and undergoing
laparoscopic or open cholecystectomy.
• Differentiate between acute and chronic
pancreatitis.
• Describe the nursing management of patients
with acute pancreatitis.
GALLBLADDER
• Pear shaped organ
• Stores 30-50 mL of bile
• Collects, concentrates and stores bile until
needed for digestion.
• Releases bile into the duodenum via the
common bile duct when fat is present.
BILIARY CONDITIONS
• Extremely common
• Interfere with the normal drainage of bile
into the duodenum
• 2 common problems:
a. Cholecystitis
b. Cholelithiasis
• Common in Caucasians/Native Americans
Risk Factors
• Sedentary lifestyle
• Obesity
• Multiparous women
CHOLECYSTITIS
• Acute inflammation of the
gallbladder
 May result from  stones may
obstructing the outflow of bile
 S/S pain in the ® upper abdomen
that may radiate to the ® shoulder,
tenderness, rigidity ® upper
abdomen
CHOLECYSTITIS
Acalculous
Acalculous

Gallbladder inflammation without
gallstones/absence of obstruction

Occurs after major surgical
procedures, severe trauma &
extensive burns
CHOLECYSTITIS
Calculous
• Gallbladder inflammation & stones
that obstruct bile flow
• Occurs in 90% of the clients
CHOLELITHIASIS
Calculi/gallstones—



form from the solid constituents of bile
vary greatly in size, shape & composition
increasing prevalent after 40 yrs. of
age; esp. women
GALLSTONES
PATHOPHYSIOLOGY
• Two major types of gallstones:
Pigment Stones
Cholesterol Stones
CHOLESTEROL STONES
• Account for 80% of gallbladder disease .
• There is a decrease in bile salts & an
increase in cholesterol.
• Cholesterol saturated bile causes
gallstones.
• This acts as an irritant that produces
inflammatory changes in the gallbladder.
CHOLESTEROL STONES
• Are 2-3x more common in women.
• Incidence increases with clients with
diabetes.
• Stones are usually smooth & are whitish
yellow to tan in color.
CLINICAL
MANIFESTATIONS
PAIN/BILIARY COLIC
• Classic symptom
• Spasms occur in order to move the stone
through the duct.
• Excruciating ® upper abdominal pain
• May occur 3-6 hours after a heavy meal
• May require analgesics  meperidine
JAUNDICE
• Appears when the Common Bile Duct (CBD)
obstruction is present.
• Bile is no longer carried to the duodenum–
absorbed in the blood.
• Pruritus
• Concentration of bilirubin > 2.5
VITAMIN DEFICIENCY
• Obstruction of bile flow interferes with
absorption of fat soluble vitamins 
intestines.
• Vitamin A, D, E, K, deficiencies may be
seen.
CHANGES in URINE &
STOOL COLOR
• Urine takes on a very dark color.
• Stool no longer with bile pigments
DIAGNOSTIC FINDINGS
• Abdominal x-ray
• Ultrasonography
• Endoscopic Retrograde
Cholangiopancreatography – ERCP
* nursing implications
ERCP
• Flexible fiberoptic endoscope that allows
for visualization of the hepatobiliary
system/place stents.
• 90% of the clients do well with this
procedure.
• The stone may be extracted or left in the
duodenum to pass naturally.
MEDICAL MANAGEMENT
Major Objective:
1. Reduce the episode of gallbladder pain &
inflammation by supportive & dietary
management.
2. Remove the cause of cholecystitis by
pharmacological therapy, endoscopic
procedures or surgical interventions.
NUTRITIONAL &
SUPPORTIVE THERAPY
• Low- fat diet
• Foods to avoid
• Remind client that fatty foods may bring
on an episode of cholecystitis.
PHARMACOLOGIC
THERAPY
• Cholestyramine (Questran)
• Urosdeoxycholic acid (Actigall) &
Chenodiol (Chenix) are medications used
to dissolve small gallstones/composed of
primarily cholesterol .
• 6-12 months of therapy is required to
dissolve stones.
• Indicated for clients who refuse
surgery/surgery is to risky.
NONSURGICAL REMOVAL of
GALLSTONES
Extracorporal Shock Wave Lithotripsy
a. Noninvasive procedure
b. Uses repeated shock waves to
disintegrate gallstones.
c. Requires no incision & no hospitalization.
d. Has been replaced – Laproscopic
Cholecystectomy
SURGICAL MANAGEMENT
Done to:
a. Relieve persistent symptoms
b. Remove the cause of the biliary colic
c. Treat acute cholecystitis
LAPROSCOPIC
CHOLECYSTECTOMY
• Standard of care for Rx. of gallstones.
• Small incision is made through the
abdominal wall at the umbilicus.
• 4 small incisions are made through the abd.
wall to introduce other surgical
instruments.
• Abdomen is insufflated with carbon dioxide
– assists in visualizing abd. structures.
LAPROSCOPIC
CHOLECYSTECTOMY
Advantages :
a. Short hospital stay
b. Less invasive /shorter healing time
c. Less post-op pain/less opiod use
d. Early ambulation
e. Able to resume full activity in about 3-4
days.
f.
Incision care is minimal
CHOLECYSTECTOMY
• Gallbladder is removed through abdominal
incision.
• Drain may be placed – near the gall
bladder bed & brought out through a
puncture site for drainage.
• Drain usually kept in placed for 24 hrs.
then removed.
CHOLECYSTECTOMY
Post-op Nursing Interventions:
• Relieve the pain
• Improve the respiratory status
• Improve the nutritional status
• Skin integrity/drainage
NURSING
INTERVENTION
• Fowler’s position
• May have NGT
• NPO until bowel sounds return, then a soft, lowfat, low-carbohydrate, high protein diet
postoperatively
• Care of biliary drainage system
• Administer analgesics as ordered and medicate to
promote/permit ambulation and activities,
including deep breathing
• Turn, and encourage coughing and deep breathing,
splinting to reduce pain
• Ambulation
Patient Teaching
• Medications
• Diet: at discharge, maintain a nutritious diet and avoid
excess fat. Fat restriction is usually lifted in 4–6
weeks.
• Instruct in wound care, dressing changes, care of Ttube
• Instruct patient and family to report signs of
gastrointestinal complications, changes in color of
stool or urine, fever, unrelieved or increased pain,
nausea, vomiting, and redness/edema/signs of
infection at incision site
PANCREAS
• Located in upper abdomen
Functions
• Exocrine function
• Secrete digestive enzymes into the GI tract
through the pancreatic duct.
• Amylase, trypsin, lipase
• Endocrine function
• secretes insulin, glucagon, and somatostatin
directly into the blood stream
Pancreatitis
• Characterized by the release of
pancreatic enzymes into the tissue of the
pancreas itself  hemorrhage and
necrosis
• Can be acute or chronic
• Hospitalizations for acute pancreatitis
have increase over the last 15 years
• Alcoholism and gall stones are the
primary risk factors.
Acute Pancreatitis
• The pancreatic duct becomes obstructed
and enzymes back up into the duct,
causing auto digestion and inflammation of
the pancreas.
• Minimal organ dysfunction is present.
• Characterized by edema and inflammation
which is confined to the pancreas.
• Affects all ages – common in middle-aged
men/women
• 3x higher in Afro-Americans than
Caucasians
Risk Factors
• Gallstones – leading cause
• Alcoholism
• Trauma
• Infection -- viral
Acute Pancreatitis
• Self- digestion of the pancreas by its own
enzymes  especially trypsin.
• This causes injury to the pancreatic cells or
activation of the pancreatic enzymes in the
pancreas rather than the intestines.
• Activated trypsin is in the pancreas. This enzyme
can digest the pancreas and can activate other
proteolytic enzymes.
Acute Pancreatitis
Clinical Manifestations
• Abdominal pain
• Pain not relieved not by vomiting
• Abdominal tenderness with muscle guarding
• Bowel sounds may be absent/diminished
• Hypotension, fever, jaundice
Acute Pancreatitis
Assessment/Diagnostic Findings
• Serum amylase and lipase levels increased
• Other findings – increase in liver enzymes,
bilirubin, triglycerides .
• X-rays of the chest and abdomen
• Abdominal ultrasound
Acute Pancreatitis
Nursing management
Relieve pain and discomfort
• Parenteral opioids
• Nonpharmacologic interventions
• Bedrest
• Frequent oral care
• NGT suction
• Clouded sensorium
Acute Pancreatitis
Nursing management
Improve breathing patterns
• Semi-Fowler’s position
• Change in position
• Monitor pulse oximetry
• C,DB/Incentive Spirometry
Acute Pancreatitis
Nursing Management
Improve nutritional status
• Oral food/fluid intake in not permitted.
• Monitor lab results/daily weights
• Avoid heavy meals/alcoholic beverages
• Diet – high CHO, low fats, low proteins.
CHRONIC PANCREATITIS
• Progressive inflammatory disorder with
destruction of the pancreas.
• Cells are replaced by fibrous tissue.
• Repeated attacks of pancreatitis occur
that increase pressure within the
pancreas.
• Obstruction of the pancreatic and
common bile ducts and destruction of the
secreting cells of the pancreas occur.
CHRONIC PANCREATITIS
Etiology
• Excessive and prolonged alcohol
consumption
• Malnutrition
• Median age 35-45 years old
PANCREATITIS
acute
chronic
Severe abdominal pain
Patient appears acutely ill
Abdominal guarding
Nausea and vomiting
Fever, jaundice,
confusion, and agitation
may occur
• Ecchymosis in the flank or
umbilical area may occur
• May develop respiratory
distress, hypoxia, renal
failure, hypovolemia, and
shock
• Recurrent attacks of
severe upper
abdominal and back
pain accompanied by
vomiting
• Weight loss
• Steatorrhea
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Chronic Pancreatitis
Assessment /Diagnostic Findings
• Serum lipase and amylase slightly elevated
• Serum bilirubin increased
• ERCP makes the diagnosis
• Stool samples
Chronic Pancreatitis
Goals
• Prevent further attacks
• Relief of pain
• Control of pancreatic endocrine/exocrine
insufficiency
Chronic Pancreatitis
Nonsurgical management
• Diet
• Pancreatic enzyme products
• Antacids/H2 antagonists
Chronic Pancreatitis
Surgical Management
• Choledochojejunostomy
• Roux-en-Y