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Nursing of Adult Patients with Medical & Surgical Conditions

Nursing of Adult Patients with Medical & Surgical Conditions. Gastrointestinal Accessory Organ Disorders. Diagnostic Studies. Serum Bilirubin Test Normal Values Direct bilirubin: 0.1 to 0.3 mg/dl Indirect bilirubin: 0.2 to 0.8 mg/dl Total bilirubin: 0.1 to 1.0 mg/dl

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Nursing of Adult Patients with Medical & Surgical Conditions

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  1. Nursing of Adult PatientswithMedical & Surgical Conditions Gastrointestinal Accessory Organ Disorders

  2. Diagnostic Studies • Serum Bilirubin Test • Normal Values • Direct bilirubin: 0.1 to 0.3 mg/dl • Indirect bilirubin: 0.2 to 0.8 mg/dl • Total bilirubin: 0.1 to 1.0 mg/dl • Total bilirubin in newborns: 1 to 12 mg/dl • Rationale • Used to diagnose liver disease, biliary obstruction, erythroblastosis fetalis, and hemolytic anemia • Nursing Interventions • NPO

  3. Diagnostic Studies • Liver Enzyme Tests • Normal Values • AST (SGOT): 5-40 IU/L • elevated with MI, hepatitis, cirrhosis, hepatic necrosis, hepatic tumor, acute pancreatitis, acute renal failure, and acute hemolytic anemia • ALT (SGPT): 5-35 IU/L • elevated with hepatitis, cirrhosis, hepatic necrosis, hepatic tumors, and hepatotoxic drugs. • LDH: 45-90 U/L • elevated with MI, pulmonary infarction, hepatic disease, pacreatitis, hemolytic anemia, and skeletal muscle disease.

  4. Diagnostic Studies • Alkaline Phosphatase: 30-85 ImU/L • elevated in obstructive disorders of the biliary tract, hepatic tumors, cirrhosis, primary and metastatic tumors, hyperparathyroidism, metastatic tumor in bones and healing fractures • Gamma GT: 4-38 U/L • elevated with hepatitis, cirrhosis, hepatic tumors, hepatotoxic drugs, MI (4-10 days after), CHF, and alcohol ingestion • Rationale • Liver is storehouse for many enzymes • Injury or diseases affecting the liver will cause release of these enzymes into the bloodstream

  5. Diagnostic Studies • Serum Protein Test • Normal Values • Total Protein: 6-8 g/dl • Albumin: 3.2-4.5 g/dl • Globulin: 2.3 to 3.4 g/dl • Albumin globulin (A/G ratio): 1.2 to 2.2 g/dl • Rationale • The liver metabolizes protein, esp. albumin. If the liver is diseased it loses the ability to metabolize the albumin and the serum albumin level is decreased

  6. Diagnostic Studies • Oral Cholecystography (Gallbladder Series) • Rationale • Provides x-ray visualization of the gallbladder after ingestion of a radiopaque dye. • The following factors are necessary for adequate dye concentration: • Ingestion fo correct number of dye tablets • Adequate absorption of the dye from the GI tract; no vomiting or diarrhea • Abstinence from food the morning of the test • Patency of the cystic duct • Concentration of the cye within the gallbladder

  7. Diagnostic Studies • Nursing Interventions • Assess for allergies to iodine • Administer 6 Telepaque tablets orally, after the evening meal • NPO after midnight

  8. Diagnostic Studies • Intravenous Cholangiography (IV Cholangiogram) • Rationale • Radiographic dye is administered IV • Allows visualization of the hepatic and common bile ducts and also the gallbladder if the cystic duct is patent • Used to visualize stones, strictures, or tumors of the hepatic duct, common bile duct, and gallbladder.

  9. Diagnostic Studies • Operative Cholangiography • Rationale • Common bile duct is injected directly with radiopaque dye. • Visualization of stones or other obstructions during surgery to prevent unneccessary common bile duct exploration

  10. Diagnostic Studies • T-Tube Cholangiogram • Rationale • Demonstrates good flow of contrast into the duodenum • Diagnose retained ductal stones and/or leaks in ducts • Nursing Interventions • T-tube to closed drainage system • Cover site with sterile dressing, if t-tube removed • Assess for allergies to iodine • NPO after midnight

  11. Diagnostic Studies • Ultrasound of the Liver, Gallbladder, and Biliary System • Rationale • Visualization of deep structures by recording the reflections of ultrasonic waves directed in to the tissue • Nursing Interventions • NPO after midnight • Should be done before barium studies or after all barium has been expelled

  12. Diagnostic Studies • Gallbladder Scanning • Rationale • Injection of technetium 99 is given and scan is done to visualize the gallbladder and biliary tract • Used to diagnose acute cholecystitis • Nursing Interventions • NPO after midnight

  13. Diagnostic Studies • Liver Biopsy • Rationale • Needle is inserted through the abdominal wall into the liver to remove a piece of liver tissue • Used to diagnose cirrhosis, hepatitis, drug-related reactions, granuloma, and tumors • Nursing Interventions • Informed consent • NPO for 4-8 hours • Assess lab results for normal platelet count and prothrombin time

  14. Diagnostic Studies • After biopsy • Assess for s/s of bleeding • Vital signs every 15 min x 1hr, every 30 min x 4 hrs, then every 4 hrs • Assess for s/s of pneumothorax • Bed rest for 24 hrs

  15. Diagnostic Studies • Liver Scanning • Rationale • Radionuclide is given IV • Geiger counter is used to record the distribution of radioactive particles in the liver • Nursing Interventions • NPO after midnight

  16. Diagnostic Studies • Blood Ammonia • Normal Value • 15 to 110 micrograms/dl • Rationale • Ammonia is normally converted into urea and then excreted by the kidneys • Liver dysfunction or altered blood flow to the liver causes blood ammonia levels to rise and BUN (blood urea nitrogen) to decrease • Nursing Interventions • Notify lab if patient is currently taking Neomycin; can cause decreased ammonia levels

  17. Diagnostic Studies • Hepatitis Virus Studies • Rationale • Diagnose specific virus causing hepatitis • A, B, C, D, and E

  18. Diagnostic Studies • Serum Amylase Test • Normal Value • 25 to 125 U/L • Rationale • Damage to pancreas cells or obstruction to the pancreatic ductal flow will cause an outporing of this enzyme and absorption into the bloodstream • Levels will rise within 12 hours of onset of pancreatic disease. • Rapidly cleared by the kidneys; levels may return to normal within 48-72 hrs • Nursing Interventions • Note administration of any IV dextrose; can cause a false-negative result

  19. Diagnostic Studies • Urine Amylase Test • Normal Value • 3-35 IU/hr • Rationale • Disorders affecting the pancreas will cause elevated amylase levels in the urine because the kidneys rapidly clear amylase • Levels remain elevated in the urine for 7-10 days • Used to diagnose pancreatitis in patients who have had symptoms for 3 days or longer

  20. Diagnostic Studies • Nursing Interventions • Urine collection may be 2 hr spot urine, 6 hr, 12 hr, or 24 hr collection. • Record exact time collection is begun • Discard first urine specimen • Collect all subsequent urine, including the last urine voided exactly 2, 6, 12, or 24 hrs after collection began • Urine should be kept on ice during collection period

  21. Diagnostic Studies • Ultrasound of Pancreas • Rationale • Provides diagnostic information with the use of ultrasonography of the pancreas • Used to diagnose carcinoma, pseudocyst, pancreatitis, and pancreatic abcess • Nursing Interventions • NPO for 8 hours before test • Gas or barium will interfere with sound wave transmission

  22. Diagnostic Studies • Computerized Tomography of the Abdomen • Rationale • Cross-sectional image • Used to diagnose inflammation, tumors, cysts, ascites, aneurysm, and cirrhosis of the liver • Nursing Interventions • NPO after midnight • Some patients may experience claustrophobia

  23. Diagnostic Studies • Endoscopic Retrograde Cholangiopancreatography of the Pancreatic Duct (ERCP) • Rationale • A fiberoptic duodenoscope is inserted through the oral pharynx, through the esophagus and stomach, and into the duodenum. Dye is injected for radiographic visualization of the CBD and pancreatic duct. • Used to diagnose obstructive jaundice, remove common bile duct stones, and place biliary and pancreatic duct stents to bypass obstructions

  24. Diagnostic Studies • Nursing Interventions • NPO for 8 hours before test • Informed consent • Must remain still for 1-2 hours • After procedure • NPO until gag reflex returns • Assess for abdominal pain, tenderness and guarding • Assess for s/s of pancreatitis • abd. pain, nausea, vomiting, and diminished or absent bowel sounds

  25. Cirrhosis • Etiology/Pathophysiology • Chronic, degenerative disease of the liver • Scar tissue restricts the flow of blood to the liver • Types of cirrhosis • Laennec’s cirrhosis • history of chronic ingestion of alcohol • Postnecrotic cirrhosis • viral hepatitis, exposure to hepatotoxins, or infection • Primary biliary cirrhosis • destruction of the bile ducts • Secondary biliary cirrhosis • chronic biliary tree obstruction (gallstones, tumor, etc.)

  26. Cirrhosis • Alteration of liver function • Reduced ability to metabolize albumin • Obstruction of portal vein • Increased pressure in the veins that drain the GI tract

  27. Complications • Portal Hypertension • increased venous pressure in the portal circulation caused by compression or occlusion in the portal or hepatic vascular system

  28. Ascites • accumulation of fluid and albumin in the peritoneal cavity

  29. Esophageal Varicosities • veins in the upper part of the body distend, including the esophageal veins due to portal hypertension. They may rupture causing severe hemorrhage

  30. Cirrhosis • Hepatic Encephalopathy • Brain damage due to elevated ammonia levels • Inaapropriate behavior, disorientation, flapping hand tremors, twitching of the extremities, stupor, and coma

  31. Cirrhosis • Signs & Symptoms • Early stages • Abdominal pain • Liver is firm and easy to palpate • Late stages • dyspepsia • changes in bowel habits • constipation or diarrhea • Nausea and vomiting • gradual weight loss

  32. Cirrhosis • ascites • enlarged spleen • spider angiomas • anemia • bleeding tendencies • cannot absorb vitamin K, or produce clotting factors • epistaxis • purpura • hematuria • bleeding gums

  33. Cirrhosis • jaundice • yellow discoloration of the skin, mucous membranes and sclerae or the eyes • caused by abnormal amounts of bilirubin in the blood • mental disorientation

  34. Cirrhosis • Treatment • Eliminate the cause • alcohol, hepatotoxins, environmental exposure to harmful chemicals • Diet • Well balanced • High-calorie (2500 to 3000 cal/day) • Moderate protein (75 g/day) • Low fat • Low sodium (1000 to 2000 mg/day) • Supplemental vitamins and folic acid

  35. Cirrhosis • Antiemetics • Benadryl & Dramamine • Contraindicated: Vistaril, Compazine, and Atarax • Treatment of Complications • Ascites • Bedrest • Strict I&O • Restrict fluids to 500 -1000 cc/day • Restrict sodium to 1000-2000 mg/day • Diuretics: Aldactone, Lasix, HCTZ • Vitamin Supplements: Vitamin K, Vitamin C and folic acid • LeVeen Peritoneal-Jugular Shunt • Paracentesis

  36. LeVeen Peritoneal Jugular Shunt Paracentesis

  37. Cirrhosis • Ruptured Esophageal Varices • Maintain airway • Establish IV • Vasopressin drip to control bleeding • IV or directly into the superior vena cava • Sengstaken-Blakemore tube • Endoscopic sclerotherapy • Portacaval shunt • divert blood from the portal vein to the inferior vena cava • Blood transfusion

  38. Sengstaken-Blakemore Tube

  39. Cirrhosis • Hepatic Encephalopathy • Decrease protein in diet • Avoid drugs which are detoxified by the liver • Lactulose • Oral or retention enema • decreases the pH of the bowel which decreases the production of ammonia • Neomycin • inhibits protein synthesis in bacteria, therefore decreasing the production of ammonia

  40. Hepatitis • Etiology/Pathophysiology • Inflammation of the liver resulting from several types of viral agents or exposure to toxic substances • Hepatitis A • Most common • Incubation 10-40 days • Oral-fecal trasmission

  41. Hepatitis • Hepatitis B • Incubation 28-160 days • Transmission by contaminated serum; blood transfusion, contaminated needles, dialysis, or direct contact with infected body fluids • Hepatitis C • Incubation 2 weeks to 6 months (usually 6-9 weeks) • Transmitted through contaminated needles and blood transfusions • Hepatitis D • Coinfection with hepatitis B • Incubation 2-10 weeks

  42. Hepatitis • Hepatitis E • Fecal contamination of water • Rare in the U.S.; usually in developing countries • Incubation 15-64 days

  43. Hepatitis • Signs & Symptoms • General malaise • Aching muscles • Photophobia • Headaches • Chills • Abdominal pain • Dyspepsia • Nausea

  44. Hepatitis • Diarrhea • Constipation • Pruritus • Hepatomegaly • Enlarged lymph nodes • Weight loss • Jaundice • Dark amber urine • Clay colored stools

  45. Hepatitis • Treatment • Treat signs and symptoms • Small frequent meals • low-fat, high carbohydrate • IV fluids for dehydration • Vitamin C for healing • Vitamin B-complex for absorption of fat soluble vitamins • Vitamin K for coagulation • Avoid unnecessary medications, esp seditives

  46. Hepatitis • Gamma globulin or immune serum globulin • should be given to anyone exposed to Hepatitis A • may be given 2 weeks before and 1 week after onset of symptoms • Hepatitis B imune globulin (HBIG) • should be given to anyone exposed to Hepatitis B • Hepatitis B Vaccine • should be given to persons identified as high risk for developing Hepatitis B • healthcare personnel • high-risk lifestyle (drug users, homosexual men, prostitutes) • infants born to mothers who are Hepatitis B positive

  47. Liver Abscesses • Etiology/Pathophysiology • May be single of multiple • Abscess forms in the liver due to an invading bacteria

  48. Liver Abscesses • Signs & Symptoms • Fever • Chills • Abdominal pain and tenderness in the RUQ • Hepatomegaly • Jaundice • Anemia

  49. Liver Abscesses • Treatment • IV antibiotics • Percutaneous drainage of liver abscess • Open surgical drainage

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