Gallbladder and Chronic Pancreatitis 2024F PDF

Gallbladder and Chronic Pancreatitis Sue Cagir DNP, MS, RN, CNE Elmira College NSG 3110 Student Learning Outcomes Identify the structure and function of the biliary tract and pancreas Describe the pathophysiology, clinical manifestations and medical management of cholelithiasis Use the nur...

Gallbladder and Chronic Pancreatitis Sue Cagir DNP, MS, RN, CNE Elmira College NSG 3110 Student Learning Outcomes Identify the structure and function of the biliary tract and pancreas Describe the pathophysiology, clinical manifestations and medical management of cholelithiasis Use the nursing process as a framework for care of patients with cholelithiasis and those undergoing laparoscopic or open cholecystectomy Differentiate between acute and chronic pancreatitis Apply the nursing process as a framework for care of patients with chronic pancreatitis Explain the nutritional and metabolic effects of surgical treatment of tumors of the pancreas The Gallbladder and Bile The main function of the Gallbladder is to store bile Bile- helps the body digest fat It is produced in the liver and stored in the gallbladder Gall Bladder Disease Two Types: Contributing Factors: Cholecystitis – inflammation of the More common in females gallbladder Obesity Cholelithiasis – presence of stones in the gallbladder High-fat diet Can lead to Cholangitis a condition Older adults that causes inflammation of the bile ducts Type 2 Diabetes Fever and Chills Jaundice Dark Urine, Clay Colored Stool  Gallbladder Disease- Manifestations Sharp right upper quadrant, epigastric, or shoulder pain Nausea, Vomiting, and ingestion of high-fat foods Murphy Sign – pain when the examiner's hand presses the gallbladder Flatulence Dyspepsia (Indigestion) Dark Urine – could contain bile Clay Colored Stool (whitish-gray) Gallbladder Disease- Diagnostic Procedures Ultrasound Hepatobiliary (HIDA) Scan Endoscopic retrograde cholangiopancreatography (ERCP) NPO eight hours before and until a gag reflex returns Monitor vital signs for complications Cholangiography Gallbladder Disease – Nursing Intervention Administer analgesics as prescribed Prevent fluid and electrolyte balance Maintain a low-fat diet Provide postoperative care Cholecystectomy Open Surgical procedure to remove the gallbladder May have a T-tube 1 to 2 weeks post-op Monitor drainage; keep below the level of the Gallbladder Empty collection bag every 8 hours Report drainage amounts greater than 1,000 mL/day Never irrigate without a healthcare provider's order Observe the color of the stool. Monitor for indications of postcholecystectomy syndrome (manifestations of cholecystitis after surgery) and report to the surgeon. Cholecystectomy T-Tube T-Tube T-Tube Medications Analgesics: morphine or hydromorphone (acute biliary pain) ketorolac (mild to moderate pain) Antiemetics Anticholinergics Ursodeoxycholic acid and chenodiol can be used to nonsurgically dissolve stones Antibiotics Therapeutic Measures Sphincterotomy with stone removal may be done with ERCP Extracorporeal shock wave lithotripsy (ESWL) to break up stones (only for small stones) Cholecystectomy Laparoscopic cholecystectomy Open Surgical Procedure Robotic Surgery ESWL Client Education Resume a regular low-fat diet Prevent dumping syndrome –rapid gastric emptying Bloating Sweating Abdomen cramps and pain Care of T-Tube (post-discharge) NCLEX A nurse if completing preoperative teaching for a client who is scheduled for laparoscopic cholecystectomy. Which of the following should be included in the teaching? A. “The scope will be passed through your rectum” B. “You might have shoulder pain after surgery” C. “You will have a Jackson-Pratt drain in place after surgery” D. “You should limit how often you walk for 1 to 2 weeks” NCLEX  A nurse is reviewing nutrition teaching for a client who has cholecystitis. The nurse should identify which of the following food choices can trigger cholecystitis?  A. Brownie with nuts  B. Bowl of mixed fruit  C. Grilled turkey  D. Baked Potato  Metabolizes drugs Pancreas Functions Helps in blood clotting Filters the Blood Synthesizes proteins such as albumin and coagulation factors Metabolizes glucose, protein, and fat Synthesizes lipoproteins (VLDL, HDL) Makes Vitamin D Detoxifies/ excretes bilirubin and other toxins Forms bile Pancreatic Disorders Acute Pancreatitis – inflammation of the pancreas caused by autodigestion by exocrine enzymes. –It is life-threatening Chronic Pancreatitis – a progressive disease of the pancreas characterized by remissions and exacerbations resulting in diminished function –irreversible recurrent damage, inflammation to cells of the pancreas Contributing Factors: Alcohol use disorder Infection Gallstones Blunt Abdominal Trauma Illegal Drug Use Operative manipulation and Trauma Cystic Fibrosis  Pancreatic Disorders - Manifestations Severe mid-epigastric or left upper quadrant pain Pain intensifies after meals and when lying down, drinking alcohol, or a high-fat meal. Nausea and Vomiting Weight Loss, Hyperglycemia Jaundice (yellow skin) Amylase – breaks down carbohydrates Dark Urine (bile in urine) into glucose Abdominal Tenderness; ascites Protease- breaks down proteins Elevated Amylase and Lipase Lipase- breaks down fat (Lipids = Fats Steatorrhea –oily, frothy, fatty stool Turner Sign Cullen’s Sign  Cullen Sign – Periumbilical area Turner Sign Bluish gray discoloration of the flank area  Pancreatitis – Diagnostic Procedures Laboratory Profile Liver Enzymes AST ↑ Amylase ALT ↑ Lipase Bilirubin –made during the ↑ WBCs breakdown of RBC –cleared through the liver- not cleared causes jaundice. ↑ Bilirubin Pancreatic Enzymes ↑ Glucose Amylase ↑ Platelets Lipase ↓ Calcium Protease ↓ Magnesium Cat Scan with contrast Nursing Interventions Dietary Management NPO initially After 24 to 48 hours, begin jejunal feeding When food is tolerated, advance to small, frequent moderate to high carbohydrate, high protein, low-fat food Feeding into the small intestines Nursing Interventions Nasogastric Tube for the severely ill with intractable vomiting or biliary obstruction Pain management Position for comfort (fetal, sitting up, leaning forward) Monitor bowel sounds Intake and Output Monitor for indications of hypocalcemia and hypomagnesemia Monitor respirations (painful to breathe) Reassure clients and carefully explain procedures to reduce anxiety Medication Antibiotics Opioid analgesics: morphine or hydromorphone (meperidine is contraindicated) Anticholinergics – diarrhea, cramps, and intestinal spasm Pancreatic enzymes – help digest foods (chronic pancreatitis only) H2 blockers or proton pump inhibitors, antacids– protect the stomach from stress ulcers Therapeutic Measures Rest the pancreas - NPO TPN – Total Parenteral Nutrition ERCP – to create an opening in the sphincter of Oddi if the cause is gallbladder blockage Cholecystectomy Pancreatojejunostomy- (Roux-en-Y) to “reroute” pancreatic secretion to the jejunum Total Parenteral Nutrition Hypertonic solution containing dextrose, proteins, electrolytes, minerals, trace elements, and insulin prescribed according to client's needs Administered through a central line (PICC) TPN hung 24 hours- weaned off Lipids hung 12-8 hours daily Total Parenteral Nutrition – care and maintenance Before Administering, verify Monitor for signs of infection prescription and solution with Change gauze dressing every two another nurse days; transparent dressing every Administer via infusion pump seven days or per agency protocol Monitor weight daily Change IV tubing every 24 hours Monitor and record I & O, If the TPN solution is noting fluid balance temporarily unavailable, Monitor serum glucose levels administer dextrose 10% in water every 4 to 6 hours to prevent hypoglycemia  Client Education for Chronic Pancreatitis Take Enzymes before meals and snacks Follow up with all scheduled laboratory testing Nutrition: High Protein, Complex Carbohydrate (fruits, vegetables, grains) Abstain from alcohol Limit fat intake (no greasy, fatty foods) Steatorrhea and condition will be improved – if enzymes are effective Referral and Follow-up Alcohol recovery program Home health for clients requiring long–term TPN Refer to dietitian Pancreatic Enzyme Replacement-Chronic Pancreatitis ONLY Pancrelipase (Creon, Pancreaze, Recognize steatorrhea: pale, Viokace, Zenpep) loose, malodorous, stools Contains pancreatic enzymes Report persistence of side (amylase, protease, lipase) to help digest food in the intestines effects Take the medication with every Symptoms of elevated uric meal or snack acid levels; e.g., painful, Swallow whole without swollen joints crushing or chewing Symptoms of hyperglycemia; Separate antacids and e.g., frequent urination and pancreatic enzymes by two hours increased thirst and appetite Pancreatic Cancer Carcinoma has vague symptoms and is usually diagnosed in late stages after liver or gallbladder involvement High mortality rate Pancreatic Cancer Contributing Factor High intake of red meat, Older age processed meat Tobacco use Obesity Chronic pancreatitis Small number have inherited risk (genetic) Diabetes Mellitus Cirrhosis Pancreatic Cancer- Manifestations Fatigue, anorexia, flatulence Hepatomegaly jaundice (late sign Pruritus when cancer blocks the bile duct) Weight loss Ascites Palpable abdominal mass, Clay Color Stools abdominal pain that may radiate Dark Urine to the back Glucose intolerance (Hyperglycemia) Diagnostic Procedure Carcinoembryonic Antigen (CEA) Levels Expected findings: less than 2.5 nonsmoker – less than 5 ng/ml smoker Critical finding- greater than 6 ng/ml Elevated serum amylase and lipase Elevated alkaline phosphatase and bilirubin ERCP Ultrasound CT Scan Nursing Interventions Palliative care measures Pain management Monitor blood glucose levels Provide nutritional support (enteral supplements and TPN) Medications Opioid analgesics morphine or hydromorphone Therapeutic Measures Chemotherapy may be used to shrink the tumor size. The nurse needs to monitor for myelosuppression and pancytopenia Radiation Therapy Partial pancreatectomy for small tumors Whipple Procedure (Pancreatoduodenectomy) Is the most common operation to remove (resect) pancreatic cancers The procedure is done when cancer is located in the head of the pancreas It involves removing the head of the pancreas, duodenum, part of the jejunum, stomach gallbladder, and possible spleen. The pancreatic duct is reconnected to the common bile duct, and the stomach is connected to the jejunum. It may be done laparoscopically Nursing Interventions Provide routine postoperative care Monitor nasogastric tube output --observe for bloody or bile-tinged drainage, which can indicate anastomotic disruption. Maintain a semi-Fowler’s position to prevent stress on the suture line Facilitate coughing, deep breathing, and use of incentive spirometer Monitor blood glucose and administer insulin as needed Provide analgesia Client Education Encourage the client to seek palliative care at home, in a cancer support group, and in available community resources. Support measures for pain, anorexia, and weight loss  NCLEX  A nurse completes the admission assessment of a client with acute pancreatitis. Which of the following findings is the priority to report?  A. History of cholelithiasis  B. Elevated serum amylase level  C. Decrease in bowel sounds upon auscultation  D. Hand spasms present when blood pressure is checked  NCLEX  A nurse is completing nutrition teaching for a client who has pancreatitis. Which of the following statements by the client indicates an understanding of the teaching? Select all that apply:  A. “I plan to eat small frequent meals.”  B. “I will eat easy-to-digest foods with limited spice.”  C. “I will use skim milk when cooking.”  D. “I plan to drink regular cola.”  E. “ I will limit alcohol intake to two drinks per day.”  References Brunner & Suddarth's Textbook of Medical-Surgical Nursing(15th ed.). (2022). Philadelphia, PA: Wolters Kluwer. Content mastery series review model: RN Adult Medical Surgical Nursing (11.0 ed.). (2018). ATI Nursing Education.