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Nursing Care and Interventions with Diseases

of the Liver, Gallbladder & Pancreas

Keith Rischer RN, MA, CEN

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Today’s Objectives…

Review pathophysiology and systemic manifestations of the inflammatory response.

Compare and contrast pathophysiology & manifestations of diseases of the liver, pancreas and gallbladder.

Interpret abnormal laboratory test indicators of liver, pancreatic and gallbladder function.

Identify the diagnostic tests, nursing priorities, and client education with diseases of the liver, pancreas and gallbladder.

Analyze assessment data from clients with cirrhosis to determine nursing diagnoses and formulate a plan of care for clients with diseases of the liver, pancreas and gallbladder.

Prioritize assessment based nursing care for clients experiencing chronic pancreatic or gall bladder disease.

Integrate nutrition therapy in care of clients with hepatic, pancreatic or gallbladder disease.

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Inflammatory Response

Occurs in response to injury

Localized Immediate Beneficial Appropriate level of

response Non Specific

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What is a Mast Cell?

Bag of Granules Located in connective

tissue• close to blood vessels

Histamine released• Increase blood flow• Increase vascular

permeability• Binds to H1, H2

receptors

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Causes

Bacteria-viral Trauma Lacerations Allergic response Bites Burns

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Purpose of inflammation

Neutralizes and Dilutes Toxins

Removes necrotic materials

Provides an environment for healing

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Systemic Manifestations of Acute Inflammation

Fever/chills• Benefits

Increased killing of microorganisms Increased phagocytosis by neutrophils Increased activity of interferon

Leukocytosis Plasma Proteins

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Patho Review

Liver• Produces bile…elimination

of bilirubin• Drug/hormone metabolism• CHO-fat-protein

metabolism• Clotting factor synthesis• Storage of vitamins &

minerals

Gallbladder• Store & concentrate bile

Pancreas• Endocrine• Exocrine

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Hepatitis

Definition: Inflammation of the

Liver

Causes: • Viral (most common)

A, B, C, D, E

• Toxic Amiodorone, Tylenol,

statins

• Alcohol

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Hepatitis ATHINK FECAL-ORAL

Etiology: Hepatitis A Virus• Incubation period: 15-50 days• Duration: 60 days• Young children asymptomatic• No chronic carrier…virus in feces during incubation pd. Before sx

apparent

Transmission: Fecal-Oral

Outbreaks occur by contaminated food/drinking water Male homosexuals Poor hygiene, improper handling of food, poor sanitary conditions

• HAV found in feces 2 or more weeks before onset of sx and up to one week after onset of jaundice

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Hepatitis A: Prevention

• Good hygiene• Water treatment• Hepatitis A vaccine

booster 6-12 mos after first dose• Immunoglobulin before exposure or within 2

weeks after exposure protects about 2 months

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Hepatitis B

THINK BODY SECRETIONS-BLOODEtiology: Hepatitis B Virus

• Incubation period: 48-180 days (mean 56-96)• Chronic & carrier status

Transmission• Exposure to infected blood, blood products or body fluids

Found in most body secretions

• Perinatal: mother to baby (10-85% liklihood) 90% become chronic carrier…25% mortality as adults

• Percutaneously (IV drug use, needle sticks) Nurses at risk!

• STD-30% cases r/t heterosexual activity• Major source of spread are healthy, chronic carriers

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Hepatitis B: Prevention

Hepatitis B vaccine • series of 3; use of HBIG for post-exposure

prophylaxis

Screening of donor blood Use of disposable equipment Sterilization of non-disposable equipment Abstinence/condom use Needle exchange programs Use of standard precautions and PPE

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Hepatitis C

THINK BLOOD-IV DRUG USEEtiology: Hepatitis C Virus

• Incubation period: 14-180 days (mean 56)• Sx persist 2-12 weeks• Most common cause of chronic hepatitis, cirrhosis, liver CA• Most are asymptomatic carriers-spread to others

Transmission Percutaneous-contaminated needles Bloodborne pathogen

• Before 1990 most cases due to contaminated blood• IV drug use, needle sticks (tattoo/body piercing)• Perinatal/sexual contact uncertain

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Hepatitis C:Prevention

Screening of donor blood Use of disposable equipment Sterilization of non-disposable equipment Abstinence/condom use No vaccine or use of IG at this time

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Chronic Hepatitis

Responsible for most cases of cirrhosis, liver CA• HCV responsible for 80% cases• Smolders over years…silently destroying liver

cells

Most asymptomatic but then develop…• Malaise• Easy fatigability• Jaundice • Hepatomegaly

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Hepatitis-Cirrhosis: Laboratory Assessment

AST-Aspartate aminotransferase ALT-Alanine aminotransferase ALP-Alkaline Phosphatase Total bilirubin Albumin Ammonia INR-Prothrombin time (PT)

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Hepatitis-Cirrhosis: Early Clinical Manifestations

• Fatigue• Significant change in weight• Gastrointestinal symptoms• Abdominal pain and liver tenderness• Pruritus

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Hepatitis-Cirrhosis: Late Clinical Manifestations

• Jaundice and icterus• Dry skin• Rashes• Petechiae, or ecchymoses (lesions)• Peripheral dependent edema of the

extremities and sacrum

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Hepatitis: Endstage Complications

Mortality 1%• Higher w/elderly & other

underlying

debilitating disease

Hepatic failure• Ascites

Chronic hepatitis Cirrhosis Hepatic cancer Liver transplant

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Hepatitis: Care Planning Priorities

Fatigue• Physical rest• Nutritional intake

Sm. Frequent meals High carb-low fat

Nausea Knowledge deficit

• Avoid Tylenol, ETOH• Diet

Drug therapy• Interferon: SQ and po

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Cirrhosis

Patho• Inflammation• Causes

ETOH Hepatitis C

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Cirrhosis: Physical Assessment

Massive ascites Hepatomegaly (liver

enlargement) Assess nasogastric

drainage, vomitus, and stool for presence of blood

Bruising, petechiae, enlarged spleen

Neurologic changes

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Complications: Cirrhosis

Portal hypertension Ascites Bleeding esophageal

varices Coagulation defects

• Vitamin K not absorbed Jaundice

• Primary liver disease• Intra-hepatic obstruction

Portal-systemic encephalopathy with hepatic coma• Ammonia levels

lactulose

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Cirrhosis: Care Planning Priorities

• Excess fluid volumeDiureticsLow sodium dietParacentesis

• Risk for imbalanced nutrition• Chronic pain• Risk for impaired skin integrity• Potential for hemorrhage

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Cirrhosis: Nursing Priorities

Fluid-electrolyte management• Na+, K+, BUN, • I&O

Bleeding precautions• Assess INR-PT-platelet-Hgb• Monitor ortho’s• Assess sx bleeding

Neurologic assessment/monitoring• Assess ammonia levels• Monitor LOC/orientation• Fall risk

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Liver Case Study

67yr male PMH: DMII, ETOH abuse, high cholesterol, PAF, CRI,

Kidney CA 2001, cardiomyopathy CC: painless jaundice that started appx 4 weeks ago

when wife noted eyes becoming yellow…did not seek medical care right away

Became visibly jaundiced, developed dark urine, stools light in color, weak but no N-V-D or abd pain

MD office: Bili of 25. Amiodorone and Lipitor DC’d. US abd done

• Hepatic duct dilation w/further testing found to have pancreatic mass

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Liver Case Study

VS: T-97.8 P-65 R-20 BP-90/37 sats 96% 2l n/c BMI 33.6 Dx:

• CXR: cardiomegaly, pulmonary vascular congestion, mild CHF

Assessment:• Conjuctival icterus, as well as skin• Bibasilar crackles• CV-no edema• GI:abd distended, BS present• Neuro: oriented x3 but lethargic

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Labs

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Liver Case Study

Nursing Priorities… Medical Priorities… GI

• Pancreatic malignancy• Hepatitis/cirrhotic liver

CV• Hypotension• AFib• Dilated cardiomyopathy

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Acute Cholecystitis-Cholelithiasis

Incidence/Prevalence• 20% US population impacted

Risk Factors• Sedentary lifestyle• Obesity• Middle aged Caucasian

women• High cholesterol• Estrogen-BCP

Patho• Inflammation• Gallstones

Cholesterol/bile salts Cystic duct obstruction or

may lie dormant in GB

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Acute Cholecystitis-Cholelithiasis:Clinical Manifestations (chart 63-1 p.1398)

Upper abd. pain• RUQ or epigastric

Rebound tenderness Episodic or vague Radiation to right

shoulder

• Triggered by high fat/large meal

Anorexia N&V Fever

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Acute Cholecystitis-Cholelithiasis Diagnostic & Interventions

Laboratory Findings• WBC

Diagnosis• CT or US

Interventions• Nonsurgical

Diet Pharmocological

• Surgical laparoscopic

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Acute Cholecystitis-Cholelithiasis: Nursing Priorities

Acute pain Impaired skin integrity Risk of infection Knowledge deficit

• Pain management• Diet therapy

Low-fat Smaller, more frequent meals

• Wound/incision care Signs of infection

• Activity restrictions• Follow-up care

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Acute Pancreatitis

Pancreas• Functions as both

exocrine/endocrine gland Patho

• Lipolysis• Proteolysis• Necrosis of blood

vessels• Inflammation

Theories of enzyme activation• ETOH

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Pancreatitis: Etiology

Biliary obstruction Cholecystectomy-postop Trauma Familial/genetic

Incidence/Prevalence• ETOH-holidays• Women-after cholelithiasis

Mortality• 10%• Higher w/elderly & postop

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Pancreatitis:Physical Assessment

Abdominal pain-LUQ/epigastric• Radiation to back, left

flank/shoulder

Nursing Assessment• Abdomen• Respiratory• Neuro• VS

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Pancreatitis:Laboratory/Diagnostic Assessment

Lab• Amylase• Lipase• Glucose• Bilirubin• WBC

Radiographic• CT• MRI

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Complications of Acute Pancreatitis p.1404 Table 63-2

Pancreatic infection Hemorrhage Hypovolemic or septic

shock Respiratory

• Pleural effusion• Pneumonia• Acute Resp. Distress

Syndrome (ARDS) Multisystem organ failure Disseminated

intravascular coagulation Diabetes mellitus

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Pancreatitis: Nursing Priorities

Acute Pain• PCA

Imbalanced nutrition• Nothing by mouth in early stages-7-10 days• Antiemetics for nausea and vomiting• Total parenteral nutrition• Small, frequent, moderate to high-carbohydrate, high-

protein, low-fat meals Knowledge deficit

• ETOH avoidance• Recurrent abd pain• Jaundice-clay colored stools-darkened urine

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Pancreatic Carcinoma

Etiology• Smoking• Elderly 60-80 years• Genetic

Patho• Primary vs. metastatic• Aggressive mets

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Case Study

22 year old female presents to the ED for c/o fatigue, N&V and feeling worn out the last several days with dark urine• Meds-BCP• VS: T-100.7 P-102 R-20 BP-110/74 sats 98%• Assessment

Mucous membranes tacky/dryGeneralized abd pain w/tenderness in RUQ

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Case Study: cont.

WBC: 8.8Hgb: 12.9Platelets: 125Neutrophil: 29%Lymphocytes: 64%Na-132K-3.7Creatinine-0.67Urine preg-negHeterophile-positive

Total bili-4.1Alk. Phos-389ALT-199AST-127UA

• Urobili-increased• Protein-neg• Glucose-neg• Ketones-mod• Bilirubin-abnormal• Blood-mod• Nitrite-neg• LET-negative• WBC-neg• Bacteria-3

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Case Study: cont.

Nursing priorities…

Nursing Interventions…

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Case Study

40 yr male w/seizure disorder

Chief complaint• Altered mental status• Vague abd pain• Weakness• Hypotension

Admission Labs• WBC-11,000• Hgb-12.2• Platelets-64,000• Creatinine-2.7• ALT-502• AST-219• Ammonia-68• Lipase-1947• Glucose-322• CT

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Case Study:Later… Day of Admission

Increasing lethargy, resp. distress ABG

• pH- 7.38• CO2- 40• O2- 52• HCO3- 23• O2 sats- 84• FiO2-100% vent…AC12, PEEP +5

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Case Study:Day 1

CVP-21 VS-101.2-118-24-82/40 Labs

• WBC-12.7• Platelets-56• Creatinine-.7• ALT-243• AST-219• Lipase 523• ABG

pH-7.25 CO2-52 O2-76 O2 sats-92% FiO2-100% PEEP now +10

Weight up 8 kg Non icteric IV Infusions

• Insulin gtt• Lasix gtt• TPN-Lipids• Fentanyl gtt• Versed gtt• Levophed gtt• Neosynephrine gtt• Vasopressin gtt• Heparin gtt

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Case Study:Day 2 CVP-16 –weight up another 7.5

kg…poor u/o VS-100.5-110-24-84/44 Labs

• WBC-21.5• Hgb-12.5• Platelets-77• Creatinine-0.9• ALT-143• AST-41• Ammonia-30• Lipase 114• ABG

pH-7.11 CO2-78 O2-58 HCO3-24 O2 sats-75% Vent-FiO2-100%, +15

Treatment Plan• CRRT• IV abx-Cipro/Flagyl• Hold Lasix gtt• NG LCS• Lactulose• Wean vasoactive gtts as able• Continue all previous gtts• Pan cultures

Nursing Priorities