1 INFORMED CARING Situations with Adults and Children with Gallbladder, Liver and Pancreatic Disorders 2 JAUNDICE ä Does NOT mean hepatitis ä Increased breakdown of RBCs ä Altered bilirubin breakdown ä Impeded flow through liver or bile duct ä First seen in sclera, then skin 3 Neonatal Jaundice ä Not liver failure ä RBC breakdown ä Phototherapy 4 BILIARY ATRESIA ä Jaundice 2-3 weeks after birth ä Easy bruising ä Stools putty like ä Tea colored urine ä Abdominal/organ distension 5 4 F’s of Gallbladder ä Fair ä Fat X size of person X amount in diet ä Fertile X BCP X Multiparity ä Forty 6 Cholelithiasis ä Calculi within the duct or gallbladder ä Severe colicky, cramp-like pain X radiates to shoulder blade X Murphy's sign ä Cholecystitis: inflammation X Can be caused by trauma, fasting, TPN or abdominal surgery 7 Diagnostic Studies ä Ultrasound of abdomen 1 X not for the obese ä HIDA scan X nuclear medicine ä Cholangiograms X endoscopic X transvenous X intraoperative 8 Post-op Care ä High abdominal incision X respiratory compromise ä T-tube X patients need to know how to empty it X may clamp it prior to removal X caution not dislodged with movements ä NO Morphine X spasms of sphincter of Oddi 9 Post-op Nutrition ä Limited fat in diet X can have rapid transit times ä Potential fat soluble vitamin deficit X A, D, E and K ä Weight loss diet 10 LIVER FAILURE ä Cirrhosis ä Drug toxicity X acetaminophen, anesthetics, HCTZ, chemotherapy ä Infection ä Cancer ä ETOH is single most linked cause 11 LIVER FAILURE S/S ä Don’t show up until 80-90% failed ä Early: X anorexia, dyspepsia, flatulence X dull, heavy abdominal feeling X lassitude X palpable liver ä Watch for ETOH withdrawal 12 LIVER S/S: LATE 1 ä Jaundice 2 ä Skin lesions: X spider angiomas X caput medusa ä Endocrine Changes X gynecomastia X impotence X loss of pubic hair X amenorrhea 2 ä Peripheral Neuropathy ä Edema & Ascities ä Encephalopathy X asterixis ä Fetor hepaticus ä Hematologic X anemia X easy bruising X bleeding tendencies 13 ASCITES ä Respiratory compromise! ä Positioning ä Paracentesis ä Hypoalbuminemia ä Patient has severe dehydration!! 14 PORTAL HYPERTENSION ä Collateral circulation ä Esophageal Varicies ä Acute Bleeding X Sengstaken-Blakemore tube X Pitressin X Sclerotherapy X Banding ä Porta-caval shunt 15 HEPATIC ENCEPHALOPATHY ä Ammonia formation in gut ä Protein restriction ä Stop bleeding ä Lactulose ä Thiamine 16 Disseminated Intravascular Coagulation ä Accelerated clotting with subsequent depletion of clotting factors 3 X profuse bleeding and X thrombosis ä Fibrin-split products (FSP) ä RX: heparin, blood products and epsilon animocaproic acid ( EACA or Amicar) 17 DIC ä Careful handling X skin is fragile X watch even slight pressure ä Oozing from every needle stick ä Multiple transfusions 18 LIVER TRANSPLANTATION ä Criteria for consideration ä Ethical debate about self-contributing behaviors 19 PANCREATITIS ä ETOH ä Drugs X Oral diabetic agents, steroids, thiazides, BCP ä Trauma ä Biliary Obstruction ä Smoking 20 PANCREATITIS: Patho & S/S ä Autodigestion/Internal “Burn” X major fluid and lyte shifts ä Flatulence and steatorrhea ä Severe, deep pain radiates to the back ä Flexed position ä Elevated amylase and lipase ä Disturbed glucose metabolism 21 PANCREATITIS: Patho & S/S ä Autodigestion/Internal “Burn” X major fluid and lyte shifts ä Flatulence and steatorrhea ä Severe, deep pain radiates to the back ä Flexed position ä Elevated amylase and lipase ä Disturbed glucose metabolism 22 COLLABORATIVE INTERVENTION 4 ä Pain relief ä Fluid replacement ä Reduce pancreatic enzyme activity X NPO & NG ä Monitor for hypo/hyperglycemic reactions ä Surgery is usually AVOIDED ä Monitor for ETOH withdrawal 23 Nursing Diagnoses ä Altered Nutrition X TPN X oral care X no food or smells in room ä Risk for Fluid Volume Deficit ä Pain 24 ACUTE ABDOMEN: ä Trauma ä Obstruction ä Infection & Inflammation 25 ABDOMINAL TRAUMA ä Severe bleeding ä Peritoneal Tap/Lavage ä Open Wound Care X Bend the knees X Cover with moist dressing ä May need temp. colostomy ä High risk for peritonitis 26 ACUTE ABDOMEN: Infection & Inflammation ä Gastritis ä Appendicitis ä Cholycystitis or stones X fair, fat, forty, female ä Chronic bowel disorders ä PID ä Peritonitis 27 ACUTE ABDOMEN: Obstruction ä Sudden or gradual onset Z prior GI problems or surgery a DM 5 Y CA ä Hallmark: emesis of fecal material ä Risk of perforation 28 ABDOMINAL ASSESSMENT w Look, Listen & Feel ä Skin changes X color, vessels, characteristics ä Visual contour changes ä Bowel sounds ä Percuss ä Palpation 29 ASSESSMENT ä Pain X PQRST ä Rigidity ä Guarding: voluntary vs involuntary ä N & V ä Hematemesis ä Melena 30 COLLABORATIVE INTERVENTIONS ä Gastric Lavage X OD X GI Bleed ä “lavage till clear” ä H20 intoxication 31 PERITONEAL LAVAGE ä Not the same as paracentesis) ä Check color X red, yellow & brown ä Labs X amylase X culture X cell count 32 COLLABORATIVE INTERVENTIONS ä Labs X CBC ä “left shift” 6 X Amylase X Hepatic Screen ä AST & ALT 33 COLLABORATIVE INTERVENTIONS ä Parenteral fluids ä Anti-emetics ä Peristaltic agents ä Gastric Suction ä Dietary modifications 34 NURSING IMPERATIVES ä Comfort measures X pain & gas relief ä Oral care ä NG tube care ä Monitoring for complications 7.