Nursing Care and Interventions with Diseases of the Liver, Gallbladder & Pancreas

1. Nursing Care and Interventions with Diseases of the Liver, Gallbladder & Pancreas Keith Rischer RN, MA, CEN

2. 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.

3. Inflammatory Response • Occurs in response to injury • Localized • Immediate • Beneficial • Appropriate level of response • Non Specific

4. 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

5. Causes • Bacteria-viral • Trauma • Lacerations • Allergic response • Bites • Burns

6. Purpose of inflammation • Neutralizes and Dilutes Toxins • Removes necrotic materials • Provides an environment for healing

7. Systemic Manifestations of Acute Inflammation • Fever/chills • Benefits • Increased killing of microorganisms • Increased phagocytosis by neutrophils • Increased activity of interferon • Leukocytosis • Plasma Proteins

8. 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

9. Hepatitis Definition: • Inflammation of the Liver Causes: • Viral (most common) • A, B, C, D, E • Toxic • Amiodorone, Tylenol, statins • Alcohol

10. Hepatitis A THINK 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

11. 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

12. Hepatitis B THINK BODY SECRETIONS-BLOOD Etiology: 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

13. 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

14. Hepatitis C THINK BLOOD-IV DRUG USE Etiology: 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

15. 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

16. 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

17. Hepatitis-Cirrhosis: Laboratory Assessment • AST-Aspartate aminotransferase • ALT-Alanine aminotransferase • ALP-Alkaline Phosphatase • Total bilirubin • Albumin • Ammonia • INR-Prothrombin time (PT)

18. Hepatitis-Cirrhosis: Early Clinical Manifestations • Fatigue • Significant change in weight • Gastrointestinal symptoms • Abdominal pain and liver tenderness • Pruritus

19. Hepatitis-Cirrhosis: Late Clinical Manifestations • Jaundice and icterus • Dry skin • Rashes • Petechiae, or ecchymoses (lesions) • Peripheral dependent edema of the extremities and sacrum

20. Hepatitis: Endstage Complications • Mortality 1% • Higher w/elderly & other underlying debilitating disease • Hepatic failure • Ascites • Chronic hepatitis • Cirrhosis • Hepatic cancer • Liver transplant

21. 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

22. Cirrhosis • Patho • Inflammation • Causes • ETOH • Hepatitis C

23. Cirrhosis: Physical Assessment • Massive ascites • Hepatomegaly (liver enlargement) • Assess nasogastric drainage, vomitus, and stool for presence of blood • Bruising, petechiae, enlarged spleen • Neurologic changes

24. 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

25. Cirrhosis: Care Planning Priorities • Excess fluid volume • Diuretics • Low sodium diet • Paracentesis • Risk for imbalanced nutrition • Chronic pain • Risk for impaired skin integrity • Potential for hemorrhage

26. 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

27. 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

28. 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

29. Labs

30. Liver Case Study • Nursing Priorities… • Medical Priorities… • GI • Pancreatic malignancy • Hepatitis/cirrhotic liver • CV • Hypotension • AFib • Dilated cardiomyopathy

31. 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

32. 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

33. Acute Cholecystitis-Cholelithiasis Diagnostic & Interventions • Laboratory Findings • WBC • Diagnosis • CT or US • Interventions • Nonsurgical • Diet • Pharmocological • Surgical • laparoscopic

34. 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

35. Acute Pancreatitis • Pancreas • Functions as both exocrine/endocrine gland • Patho • Lipolysis • Proteolysis • Necrosis of blood vessels • Inflammation • Theories of enzyme activation • ETOH

36. Pancreatitis: Etiology • Biliary obstruction • Cholecystectomy-postop • Trauma • Familial/genetic • Incidence/Prevalence • ETOH-holidays • Women-after cholelithiasis • Mortality • 10% • Higher w/elderly & postop

37. Pancreatitis:Physical Assessment • Abdominal pain-LUQ/epigastric • Radiation to back, left flank/shoulder • Nursing Assessment • Abdomen • Respiratory • Neuro • VS

38. Pancreatitis:Laboratory/Diagnostic Assessment • Lab • Amylase • Lipase • Glucose • Bilirubin • WBC • Radiographic • CT • MRI

39. 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

40. 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

41. Pancreatic Carcinoma • Etiology • Smoking • Elderly 60-80 years • Genetic • Patho • Primary vs. metastatic • Aggressive mets

42. 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/dry • Generalized abd pain w/tenderness in RUQ

43. WBC: 8.8 Hgb: 12.9 Platelets: 125 Neutrophil: 29% Lymphocytes: 64% Na-132 K-3.7 Creatinine-0.67 Urine preg-neg Heterophile-positive Total bili-4.1 Alk. Phos-389 ALT-199 AST-127 UA Urobili-increased Protein-neg Glucose-neg Ketones-mod Bilirubin-abnormal Blood-mod Nitrite-neg LET-negative WBC-neg Bacteria-3 Case Study: cont.

44. Case Study: cont. • Nursing priorities… • Nursing Interventions…

45. 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 Case Study

46. 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

47. 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 Case Study:Day 1

48. 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 Case Study:Day 2