MEDICAL SURGICAL NURSING CHAPTER 53

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MEDICAL SURGICAL NURSING CHAPTER 53

• CARING FOR CLIENTS WITH DISORDERS OF THE LIVER,
  GALLBLADDER PANCREAS

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LIVER

• Functions see box 53-1
• Hepatic parenchymal cells perform the metabolic
  functions

• Kupffer cells work in the immunologic,
  detoxifying, blood-filtering actions of the
  liver
• Unless it is enlarged, the liver is usually not
  palpable

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Jaundice (Icterus)

• A greenish, yellow discoloration of the tissue
  the skin, mucous membranes of the mouth the
  sclera
• Not a disease in itself, but it is the most
  common sign of a liver disorder
• Occurs if serum bilirubin levels are 2.5mg/dl or
  greater which can occur due to
• excessive destruction of RBCs
• liver cannot excrete bilirubin normally

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Table 53-1 Types of Jaundice

• hemolytic jaundice excess destroyed RBCs
• hepatocellular jaundice caused by liver
  disease
• obstructive jaundice caused by a blockage in
  the passage of bile between the liver the
  intestinal tract

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Cirrhosis

• A degenerative disorder of the liver caused by
  generalized cellular damage whereby the liver can
  no longer carry out its functions
• Laennecs or alcoholic cirrhosis, the most common
  type, results from chronic ETOH intake, poor
  nutrition, chronic poisoning with chemicals or
  hepatotoxic drugs like acetaminophen
• Postnecrotic caused by destruction of liver cells
  by hepatitis infection or metabolic liver disease

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CIRRHOSIS

• Biliary due to scarring around the bile ducts,
  chronic obstruction infection
• Prognosis depends on bilirubin albumin levels,
  presence of ascites, neuro involvement
  nutritional status, see table 53-2

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SIGNS SYMPTOMS

• Chronic fatigue
• Anorexia
• Dyspepsia
• N/V with weight loss
• Diarrhea or constipation
• Clay colored stools
• Tea colored urine

• Abdominal discomfort
• SOB
• Easy bruising bleeding
• Edema of legs feet
• Dilated veins over abdomen (caput medusae)
• In men, gynecomastia, testicular atrophy
• Palmar erthyema cutaneous spider angioma

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Assessment findings

• Compensated less severe s/s more vague
• Decompensated as the disease progresses, s/s
  more pronounced indicate liver failure
• Box 53-2, clinical manifestations

• Dx liver biopsy, abd CT, MRI, prolonged
  prothrombin time, low platelet counts, box 53-3
• See nursing guidelines 53-1, assisting with a
  percutaneous liver biopsy

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Medical Care

• There is no cure
• Prevent further deterioration
• Vitamin mineral supplements
• Restrict protein intake to prevent hepatic
  encephalopathy
• No ETOH intake
• Administration of platelets, RBCs
• Restrict Na fluids
• Possible liver transplant, box 53-4

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Nursing Care Plan 53-1

• Daily wts
• IO
• Measurement of abdominal girths, fig 53-4
• Medication administration with assessment of
  possible side effects
• s/s of increasing bleeding
• Watch for alcohol withdrawal symptoms if
  alcoholic
• Client family teaching 53-1

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Possible Complications of Cirrhosis

• Portal HTN blood backs up into the portal
  system which is the venous pathway through the
  liver
• S/S ascites, the accumulation of fluid in the
  peritoneal cavity, visible abd veins
  hemorrhoids fig 53-5

• Treatment reduce the fluid accumulation
  venous pressure by low Na diets, diuretic use,
  reduction of BP, creation of a surgical shunt

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ESOPHAGEAL VARICES

• Bulging esophageal veins which are vulnerable to
  bleeding, hemorrhage, located superficially in
  the mucosa of the esophagus easily traumatized
  by rough food or chemical irritation like gastric
  reflux

• S/S esophageal bleeding slight, but chronic or
  acute massive
• Medical soft diet, elimination of alcohol, ASA
  other substances that are locally irritating,
  reduction in pressure causing actions such as
  coughing, straining at stool, or surgical
  interventions

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Ascites

• A collection of fluid in the peritoneal cavity
• S/S visible, massive abdominal swelling
• Treatment abdominal paracentesis to remove
  fluid from the peritoneal cavity

• Up to 6-8 liters of fluid may be removed over 90
  minutes
• IV administration of albumin given simultaneously
  to replace that lost in the drainage. Monitor
  IO, v/s, especially BP
• Maintenance therapy low Na diet, and diuretic
  therapy with Aldactone, a K sparing diuretic

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Hepatic Encephalopathy

• A neurological complication due to increased
  serum ammonia levels. As ammonia builds up,
  crosses the blood-brain barrier, interferes with
  brain cell function
• S/S disorientation, confusion, personality
  changes, memory loss, a Babinski reflex,
  lethargy, deep coma death

• Treatment eliminating dietary protein, drugs,
  laxatives enema therapy to remove excessive
  ammonia from the blood. Administration of
  lactulose po or per rectum to remove excess
  ammonia
• Prognosis is grim

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Hepatitis

• An inflammation of the liver that may be acute or
  chronic
• Most common cause is viral infection
• Viral types table 53-3
• Other types
• Autoimmune
• Toxic
• Drug-induced

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Phases Common to all forms

• Incubation phase client asymptomatic late in
  stage virus found in blood, bile stools
• Preicteric or prodromal phase n/v, wt loss,
  anorexia
• Icteric phase jaundice, pruritis, dark urine,
  fatigue, enlargement of spleen, liver lymph
  nodes
• Posticteric phase liver enlargement, malaise
  fatigue continue while other s/s subside

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Treatment of Hepatitis

• Medical symptomatic bedrest, balanced diet
  with small frequent meals, possible IV fluids,
  vitamin supplementation, recombinant interferon
  alfa-2b ribaviran for chronic hepatitis B, C,
  D. If no response to medical treatment may
  require liver transplant
• Nursing prevention of the spread of the virus,
  rest, nutritional intake, prevention of
  complications

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Liver Tumors

• Primary malignancies rare, but related to those
  with hx of previous hepatitis B or D infections
  or cirrhosis
• S/S vague, jaundice common
• Treatment Hepatic lobectomy if affects single
  lobe. If metastatic tumor inoperable
• Nursing comfort care for terminal stages

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Disorders of the Gallbladder

• Box 53-6
• Cholelithiasis - stones that form in the
  gallbladder
• Cholecystitis is inflammation of the gallbladder,
  which may be chronic or acute

• S/S belching, nausea, RUQ pain usually after
  eating fatty, fried, greasy or spicy foods. If a
  stone is blocking the bile duct may have fever,
  tenderness over the liver, severe pain that
  radiates to the back shoulders, dark urine
  light, clay colored stools

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Medical Treatment

• Keep the client NPO progress to low fat diet
• NGT insertion
• IV fluids
• Analgesics
• Anticholinergics
• If poor surgical candidate may try to dissolve
  the stones with drugs such as Actigall
• Lithotripsy, use of shock waves to break up the
  stones fig 53-9

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Surgical Treatment

• Laparoscopic cholecystectomy preferred
• Open cholecystectomy done if gallbladder is
  extremely enlarged, many stones, or very large
  stones
• See nursing care plan 53-2

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Pancreatitis

• Inflammation of the pancreas which may be acute
  and fatal or chronic with many relapses
  recurrences
• The pancreas becomes inflammed when its own
  enzymes cause the pancreas to digest itself
  (autodigestion)
• Causes biliary disease, abd trauma,
  hyperparathyroidism, high ETOH intake or unknown
• Client usually very ill

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Acute Pancreatitis

• S/S severe mid-upper abd pain, radiating to
  both sides straight through to the back, n/v,
  gas, stools that are foul smelling, frothy and
  with the appearance of steatorrhea, aggravated by
  eating fatty foods or drinking ETOH
• Dx increased serum amylase, lipase liver
  enzymes

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Treatment

• Medical surgical
• pain relief
• reduce pancreatic secretions
• restore fluid electrolyte balances if lost
  during n/v
• prevent or treat systemic complications

• keep client NPO, NGT to suction, IV
  antibiotics, if cysts present may be drained,
  usually improve in 1 week
• If no improvement may need to do surgical
  debridement of necrotic tissue prn
• Pancreatic autotransplantation, new procedure

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Nursing care

• Monitor s/s
• v/s
• presence of ETOH withdrawal s/s
• NGT insertion management
• Foley catheter insertion management
• IV fluids
• Closely monitor blood glucose levels
• Analgesics prn
• See nursing process

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Chronic Pancreatitis

• A prolonged, progressive inflammation of the
  pancreas
• S/S persistent pain, wt loss, digestive
  disturbances, secondary development of DM
• Treatment depends on the cause of the flare up
• Nursing care same as for acute

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Cancer of the Pancreas

• Usually poor prognosis due to late dx
• S/S vague, LUQ abd pain, jaundice, anorexia
  wt loss
• DX abd ultrasound or CT, bx

• Medical/Surgical treatment radical
  pancreatoduodenectomy or Whipple procedure fig
  53-13
• Nursing care pain mgmt, management of fluid
  volume, risk for imbalanced nutrition

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General Nutritional Considerations

• A high protein diet of 1.5 to 2.0 g/kg is used to
  promote liver cell regeneration in clients with
  hepatitis
• There is a small margin of error regarding
  protein intake for clients with cirrhosis
• Coffee, both regular decaffeinated, causes a
  significant increase in plasma cholecystokinin,
  the hormone that stimulate gallbladder
  contractions

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General Pharmacologic Considerations

• Many drugs are potentially hepatotoxic. Examples
  are PCN, acetaminophen, methotrexate
  allopurinol (Zyloprim)
• In clients with liver dz, barbituates, narcotics,
  any drug metabolized or detoxified by the liver
  are contraindicated or used with caution

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General Gerontological Considerations

• Gallbladder disease is more common in older
  adults
• Older adults with chronic hepatitis dont report
  recurrent severe pain as do younger adults
• Hepatitis B vaccine should only be given to older
  adults if they are traveling to areas where they
  may be exposed to it. They have a lowered
  ability to make immunoglobulins