Nursing Management of Adults with Liver and Biliary Disorders PDF

Nursing Management of Adults with Disorders of the Liver and Biliary Tract Karmen Hice, MS, RN, CNE, CNEcl  Objectives Upon completion of this class and its related activities, using Cholelithiasis, Cholecystitis , Pancreatitis, Hepatitis and Cirrhosis as exemplars, the student will demonstrate...

Nursing Management of Adults with Disorders of the Liver and Biliary Tract Karmen Hice, MS, RN, CNE, CNEcl  Objectives Upon completion of this class and its related activities, using Cholelithiasis, Cholecystitis , Pancreatitis, Hepatitis and Cirrhosis as exemplars, the student will demonstrate the ability to: 1. Interpret assessment data, significant laboratory results, and diagnostic testing findings specific to the liver and biliary tract when developing the plan of care. 2. Create a comprehensive nursing care plan, including a discharge plan for nursing management of patients with disorders of the liver and biliary tract. 3. Analyze the impact of disorder of the liver and biliary tract on the patient regarding the following domains: physiological, psychological, and social. 4. Summarize common drugs, regarding drug actions and potential side effects, used for adult patients with liver and biliary disorders. 5. Analyze the relevance of nursing research, ethical and legal issues, advocacy roles of the nurse, and economic impact when caring for adult patients with disorders of the liver and biliary tract. Anatomy Review The Gallbladder Ch 44 [Pages 1418-1426]  The Gallbladder Distensible, sac-like Stores, concentrates and expels bile Hormones of digestion → stimulate gallbladder to contract and expels bile Gallstones are made up of cholesterol, bilirubin calcium salts and unconjugated bilirubin Terms Cholecystitis – inflammation of the gallbladder Cholelithiasis – gallstones in the gallbladder Choledocholithiasis – stones in the common duct Cholangitis – inflammation in the common duct Acute Cholecystitis Patho Diffuse inflammation of the gallbladder Usually due to obstruction (gallstones) Stone obstructed in cystic duct leads to inflammation which develops behind obstruction Treatment remove obstruction May self resolve → but continue to attack Chronic Cholecystitis Patho Repeated episodes of acute Symptoms vary Gallbladder Removal → Cholecystectomy Cholecystitis Risk Factors & Assessment Risk factors Women more than Men Age Pregnancy Obesity Underlying cause Stones vs. No stones Cholecystitis Diagnostics Table 44-1 Studies Diagnostic Uses X-Ray Stones rarely visible; Rule out other causes Ultrasonography Shows size of abdominal organs and presence of masses Magnetic resonance Visualizes the biliary tree and capable of cholangiopancreatography detecting biliary tract obstruction (MRCP) Endoscopic retrograde Visualizes biliary structures and pancreas via cholangiopancreatography endoscopy (ERCP) [Fig 44-3] Cholecystogram, cholangiogram Visualize gallbladder and bile duct Laparoscopy Visualizes anterior surface of liver, gallbladder, and mesentery through a trocar  Cholecystitis Medical Management Medications Extracorporeal Shock Surgery Collaboration Diet Wave Lithotripsy (ESWL) Cholecystectomy Rest Used in acute cases – usually low-fat liquids Analgesia Shock waves used to Antibiotics break up stones *Standard of treatment IVF As tolerated add cooked fruits, rice, lean meats, mashed potatoes, non-gas forming ursodeoxycholic acid Fragments removed by NG Suction being passed, removed w/ vegetables, bread, coffee or tea (UDCA) & chenodeoxycholic acid endoscopy or dissolved Avoid: eggs, cream/cheese, fried food, gas- forming vegetables, ETOH (chenodiol or CDCA) Used to reduce size of stones, dissolve small stone & prevent new stone formation Cholecystectomy Nursing Process Assessment Planning/ NDX Nursing Interventions Potential Complications Pre-Op Acute Pain Provide pain relief (incisional Bleeding Smoking status Impaired Gas Exchange & CO2) GI Symptoms (biliary leak or Respiratory status Impaired Skin Integrity Improve respiratory status bowel injury) ASA/NSAIDSD usage Impaired Nutritional Status Ambulate day of surgery Nutritional status Encourage turn, cough & deep breathing Post-Op Maintain skin integrity Pain Respiratory status Improve nutritional status Incision site Monitor for complications Alleviation of symptoms The Pancreas Ch 44 [Pages 1426-1438] The Pancreas 2 Functions of the Pancreas 1. Exocrine Functions Produces digestive enzymes Secretes enzymes into the small intestine 2. Endocrine Functions Releases hormones into the blood Beta cells → Insulin Alpha cells → Glucagon  Pancreatitis Patho Pancreatic Enzymes Trypsin – breakdown of proteins and activation of other pancreatic enzymes Amylase – breakdown of carbohydrates Lipase – breakdown of fats Enzymes are activated in Pancreas Backup of pancreatic secretions and activation and release of enzymes → within the pancreas → activated enzymes cause autodigestion/ self destruction of pancreatic cells and tissues → resulting in inflammation, damage to the pancreas, scarring, dysfunction and pain Acute Pancreatitis Risk Factors Gallstones ETOH abuse Biliary tract disease Bacterial or viral infection Trauma Drug toxicities Smoking Acute Pancreatitis Clinical Manifestations *Abdominal Pain sudden onset and may be severe, deep, piercing *N/V Fever *Hypotension Tachycardia Jaundice Abdominal tenderness with muscle guarding Bowel sounds may be decreased or absent Cullen's sign - a bluish periumbilical discoloration  Laboratory Test Abnormal Findings Acute Pancreatitis Diagnostics Serum amylase ↑ Serum lipase ↑ X-rays Blood glucose ↑ Abdominal Chest WBC ↑ Serum bilirubin ↑ CT Scans + ERCP Serum Ca ↓ Ultrasound Acute Pancreatitis Medical Management *Pain management Positioning - *IVF/ Electrolytes Correction of fluid & electrolyte imbalances Prevention or alleviation of shock Reduction of pancreatic secretions Monitor infected/necrotic drainage Antibiotics Prevention or treatment of infection Removal of precipitating cause Oral Feeding As soon as tolerated Preference for Enteral vs. Parenteral nutrition Nursing Management Pain Breathing Nutrition: NPO with NG tube initially Skin integrity Monitoring and managing potential complications  Chronic Pancreatitis Patho Continuous, prolonged, inflammatory, and fibrosing of the pancreas Pancreas is progressively destroyed as it is replaced by fibrotic tissue Strictures and calcifications may also occur in the pancreas Have signs and symptoms like acute pancreatitis Often have: Digestive problems because of inability to deliver enzymes to the duodenum Glucose control problems because of damage to the islets of Langerhans Signs of biliary obstruction because of underlying bile tract disorders or duct compression by tumors  Chronic Pancreatitis Medical Management Medication Pancreatic Enzyme Nutritional Therapy Lifestyle Surgery Administration Replacement Non-opioid analgesic pancrelipase (Pancrease, Small, bland, frequent meals No ETOH Indicated when biliary disease Viokase) is present, or obstruction or pseudocyst develops Insulin therapy No Smoking Improve nutritional status & reduce amount of fatty stools Surgical procedure can divert bile flow or relieve ductal obstruction Take with all meals and snacks Endoscopic Choledochojejunostomy Side effects: abdominal cramps/ pain, nausea, diarrhea Roux-en-Y procedure Pancreatic Surgery Relieve ductal obstruction may include stent placement at the site of the obstruction ERCP with Sphincterotomy Require follow up procedures to either exchange or remove the stent. Diverts bile around the ampulla of Vater Choledochojejunostomy Common bile duct is anastomosed into the jejunum Roux-en-Y Pancreatic duct is opened and an anastomosis Pancreatojejunostomy is made with the jejunum  The Liver Ch 43 [Pages 1364-1404] Portal Circulation Hepatic artery: 300 mL/min Portal vein: 1050 mL/min → from GI tract, pancreas and spleen Total blood flow: ~ 1.5 L of blood exit the liver/ minute Normal Blood Flow Portal Vein → Liver → Hepatic Vein → Empties into the vena cava → Right ventricle Liver Functions Carbohydrate Metabolism Storage of 1. Storage of glucose as glycogen Metabolism of Drugs Minerals and Vitamins 2. Synthesis of glucose 1. Vitamins A, D, and K Production of Bile Salts & Removal of Bile 1. Bile salts are reabsorbed and Fat Metabolism recycled by the liver 1. Formation of lipoproteins 2. Cholesterol production, storage 2. Bile salts enter the GI tract → and elimination emulsify fat → allows them to be 3. Formation of ketones broken down and enter the lymphatic system Protein Metabolism Filtration Metabolism of Steroid 1. Formation of urea from ammonia 1. Blood 2. Synthesis of plasma proteins Hormones 2. Removal of bacteria (albumin) 3. Elimination of bilirubin 3. Synthesis of clotting factors Fate of Bilirubin Break down of old RBCs Hemoglobin from old RBCs becomes unconjugated bilirubin The liver links unconjugated bilirubin together creating Conjugated bilirubin → Excreted with bile Removed through feces from the body → gives stool its normal color  Excess unconjugated bilirubin in the blood → not being Jaundice excreted → bilirubemia → Jaundice → yellow tint of skin & eyes HEPATITIS Hepatitis Inflammation of the liver Toxins Bacterial *Viral *Hepatitis A *Hepatitis B *Hepatitis C Hepatitis D Hepatitis E  Characteristics of Hepatitis A, Hepatitis B & Hepatitis C Point of Comparison Hepatitis A Hepatitis B Hepatitis C Causative agent Hepatitis A virus Hepatitis B virus Hepatitis C virus Spread through Water/Food Blood/ Body Fluids Direct Blood/ Body Fluids Unprotected Sex, needles/ Needles/ syringes, other equipment to Routes of Transmission Fecal-Oral syringes, birth and razors inject drugs None Infections that become chronic 5% of adults > 50% No long-term damage Decreased as of 2022 Remained Stable as of 2022 Decreased as of 2022 Infection Rates in US [~4,500 new cases] [~16,729 new cases] [~93,805 new cases] Hepatitis B & C Complications Cirrhosis, Portal HTN, Liver CA and Liver Failure Hepatitis A Hepatitis B Hepatitis C vaccine Method of prevention vaccine vaccine (not yet available) None or Preferred treatment None Antiviral Medications Severe: Interferon or Antiviral meds Jaundice Fever Fatigue Loss of appetite Nausea Vomiting Abdominal pain Joint pain Dark Urine Signs & Symptoms Clay-colored stool Diarrhea (Hepatitis A only) *Asymptomatic Hepatitis Diagnostic Tests Laboratory Test ↑ Aspartate Aminotransferase (AST) ↑ Alanine Transaminase (ALT) ↑ Lactate Dehydrogenase (LDH) ↑ Serum direct conjugated bilirubin ↑ Urinary bilirubin Prolonged PT or INR Diagnostic Test Ultrasound Enlarged liver, ascites, Splenomegaly X-Ray EGD  Hepatitis Medical Management Rest! Diet Limit Treatments Hepatic cell regeneration Adequate calories Drugs due to liver metabolism Antiviral drug, depends Metabolic demands Small Meals upon type ↑ Blood supply Antiviral Combinations Help with Liver metabolism Many symptoms Vitamin supplements CIRRHOSIS Cirrhosis Extensive irreversible scarring of the liver Common Causes ETOH Hepatitis C Hepatitis B Drugs/ toxins Autoimmune Metabolic diseases Portal Hypertension Circulation  Esophageal Varices Portal Hypertension Hemorrhoidal Varices  Cirrhosis Clinical Manifestations Portal Hypertension Increased resistance to flow in portal venous system > sustained increase in portal venous pressure Internal hemorrhoids, esophageal varices, caput medusae develop Ascites (several theories of etiology) Fluid in peritoneum (large amounts)  hydrostatic pressure from portal hypertension  oncotic pressure from  albumin synthesis Congestive splenomegaly Spleen enlarges due to shunting of blood into splenic vein Decreased life span of RBC, platelets, WBC → low levels of all Hepatic encephalopathy Neural disturbance secondary to impaired conversion of ammonia to urea →  serum ammonia levels First sign – Asterixis – flapping tremor of hands → mental confusion → coma Fector Hepaticus – musty, sweet odor on breath (build up of digestive by-products unable to be broken down) Esophageal Varices Caput Medusae Ascites Liver Failure Cirrhosis Diagnostic Tests Laboratory Test ↑ Aspartate Aminotransferase (AST) ↑ Alanine Transaminase (ALT) ↑ Lactate Dehydrogenase (LDH) ↑ Serum direct unconjugated bilirubin ↑ Urinary bilirubin Prolonged PT or INR Diagnostic Test Ultrasound Enlarged liver, ascites, Splenomegaly X-Ray EGD  Cirrhosis Medical Management Cirrhosis Collaborative Care Ascites Esophageal Varices Hepatic Encephalopathy Rest Na+ Diet Avoid bleeding/hemorrhage Avoid ammonia formation Diet Diuretics Band Ligation Antibiotics Calories (3,000 Paracentesis Balloon Tamponade Lactulose* kcal/day) Transjugular Intrahepatic Portal CHO/ Mod-Low FAT Systemic Shunt (TIPS) PRO Meds: Beta Blockers, Vasopressin, NTG, Statins B-Complex Vitamins Alcohol, irritating foods Meds: ASA, acetaminophen & NSAIDs Liver Transplant Candidate  Action Inhibit intestinal ammonia production through: Converts of ammonium (NH4) to ammonia (NH3) and the passage of ammonia from tissues into the stool Expected Outcome Lactulose Decrease in serum ammonium Improved mentation Increased number of BMs (loose stools) Side Effects Diarrhea Increased bowel sounds (borborygmi) Increased flatus Bloating Transjugular Intrahepatic Portosystemic Shunt (TIPS) A stent is inserted to connect the portal veins to adjacent blood vessels that have lower pressure. This relieves the pressure of blood flowing through the diseased liver and can help stop bleeding and fluid back up. Nursing Process Nursing Diagnosis Imbalanced nutrition: Less than body requirements Impaired skin integrity Ineffective breathing pattern Excess fluid volume Dysfunctional family processes: Alcoholism Overall Goals Relief of discomfort Minimal to no complications Return to as normal a lifestyle as possible  Nursing Interventions Nursing Interventions Nursing Interventions Patient Education Rest Skin care Symptoms of complications Between-meal nourishment Turning schedule, at least every 2 hours Written instructions with adequate Explanation of dietary restrictions ROM exercises explanations for patient/family Accurate I/O Coughing/deep breathing exercises When to seek medical attention (reportable signs and symptoms) Daily weights Monitor for electrolyte disturbances Remission maintenance Abdominal girth Diuretic therapy alters electrolytes Abstinence from alcohol Extremities measurement Hypokalemia - Cardiac dysrhythmias, Check respiratory status frequently muscle weakness BUN, creatinine Always be a supportive listener & maintain Semi- or high Fowler’s a caring attitude Observe for bleeding disorders Liver Transplant [Pages 1407-1409] Surgical procedure Removal of diseased liver Healthy liver from a cadaver or right lobe from a live donor Indication – life-threatening ESLD (end stage liver disease) Advanced chronic liver disease Hepatic failure Some malignancies Immunosuppression – to prevent rejection of the transplanted liver Several agents used Used in combinations of low doses Issues Related to Liver Transplantation Rigorous Selection Process Preparation Process Ethical Dilemmas Complications Usually has many comorbid conditions Immunosuppression Allocation of organs Bleeding Thorough evaluation of overall health Nutritional support Infection Model for End Stage Liver Disase Counseling and Education Rejection classification (MELD) Questions?