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Med-Surg Ch 25

Gallbladder, Liver, and Pancreatic Disorders

Cholelithiasis Formation of stones in the gallbladder or biliary duct system
Cholelithiasis Risk Factors Family history American Indian, or Mexican Rapid weight loss or yo-yo dieting Biliary stasis (slowed emptying) Increased estrogen, pregnancy or premenopause Diabetes or cirrhosis Obesity Elevated cholesterol Inflammation, or chronic inflammation
Cholelithiasis Symptoms Vague pain in epigastric and RUQ often occur after meal but may begin only as a vague fullness May be asymptomatic Pain in epigastrium RUQ Often radiates into the back, scapula, or shoulder Nausea and vomiting Hurts worse when the client moves
Cholelithiasis Complications Cholecystitis Obstruction of the common bile duct, causes bile reflux into the liver, leads to liver failure and pancreatitis, fatal if not corrected Gallstones can migrate into the ducts Cholangitis (Inflammation of the duct)
Cholecystitis Bile-pouch-inflammation Inflammation of the gallbladder may be acute or chronic If ischemia (restriction of blood supply) occurs this can cause tissue death known as necrosis and perforation of the gall bladder wall
Acute Cholecystitis Obstruction of duct, increased pressure Retained bile causes inflammation and can lead to ischemia Symptoms: (Biliary colic, RUQ pain and tenderness that is severe that may radiate, movement aggravates pain, Nausea/Vomiting, Possible fever and anorexia)
Chronic Cholecystitis Often asymptomatic Persistent irritation of the gallbladder by stones Can result from repeated attack of acute cholecystitis
Complications of Cholecystitis Empyema (collection of infected fluid in the gallbladder) Gangrene, perforation, with peritonitis Fistula (abnormal opening) to another organ Obstruction of the small intestine by large stone (gallstone Illius - obstruction that stops flow)
Cholecystitis Diagnostic Tests Serum (Total) bilirubin or (0.1-1.2) Direct (conjugated) Bilirubin (0.1-0.3) Rise with liver obstruction Indirect (unconjugated) Bilirubin (<1) Rise in RBC hemolysis CBC Elevation in amylase & lipase Abd x-ray Ultrasound Gallbladder scan Cholestre
Cholecystitis Medications Ursodiol (Actigall) and Chenodiol (Chenix) (gradually reduce cholesterol content of gallstones; Monitor for severe diarrhea and live function studies – hepatotoxic) Pain medication (morphine and Demerol) Cholestyramine (Questran) (for itch (pruritus))
Vitamins needed with Cholecystitis Fat-soluble (my fat dog KADE)
Cholecystitis foods to reduce or eliminate Whole-milk products (cream, ice cream, cheese) Doughnuts, deep-fried Avocados Sausage, bacon, hot dogs Gravies with fat, cream Most nuts Corn chips and potato chips Butter and cooking oils Fried foods Peanut butter Chocolate candies
Treat Cholecystitis with Cholecystectomy Dietary Management N/V = NPO Supplement vitamins if obstruction Extracorporeal shock wave lithotripsy (ESWL) May see hematuria Can effect kidneys Some sedation Complementary therapy, Goldenseal – inhibits growth of many pathogens
Cholesystectomy Post-op Care Will have pain, and gas NPO, then low-fat Ambulation Return to activities in 1 to 3 weeks Insentive sperometer, pain control
T-tube for Cholesystitis Bile drains from the duct until < edema Sterile Protect skin (like vomit; hurts, burns) Maintain accurate I/O Fowler’s position with tube inferior Some blood tinged drainage, then greenish-brown After 48hrs, report >500ml drainage in 24 hours
Gallbladder Cancer Rare, poor prognosis due to the location of the liver Anorexia, weight loss, nausea, vomiting, general malaise, jaundice, hepatosplenomegaly (enlargement of spleen and liver) Severe RUQ pain with a palpable mass Surgery, radiation, chemotherapy
Liver Basics Metabolizes protein, carbs, fat, steroid hormones, and most drugs Synthesizes blood proteins like albumin and clotting factors Detoxifies Converts ammonia to urea for kidneys excretion Produces bile Stores glycogen, minerals, and fat soluble vitamins
Effects of Hepatocellular Failure < protein metabolism < albumin and clotting factors Disturbed glucose metabolism and storage < bile production < fat-soluble vitamin absorption Impaired hormone metabolism Jaundice (Sclera, Palms, Roof of mouth, yellow blanching)
Hepatic Portal Hypertension Impaired blood flow through the liver causes high pressure in the portal vein, the large vein that brings blood from the intestine to the liver. Results in congestion and dilation of veins
Hepatic Portal Hypertension Manifestations Esophageal varicies (also hemorrhoids) Caput medusae (umbilicus vericies) Spleenomegly Ascites (< albumin, edema) Portal encephalopathy (< mental state, toxins not filtered (ammonia), cerebral edema) Hepaorenal syndrome (< blood = acute renal failure
Hepatic Portal Hypertension Complications Spleenomegaly Ascities (abd edema, < albumin, > aldosteron) Esophageal Varices Hepatic Encephalopathy (toxic blood, > ammonia, asterixis) Hepatorenal Syndrome (renal failure, < blood to kidney) Spontaneous Bact. Peritonitis (Abd pain, tender, fever)
Spleenomegaly Enlarged spleen Leads to destruction of RBC and WBC’s Anemia, leukopenia, & thrombocytopenia develop
Azotemia increased nitrogen and uria in blood
Hepatitis Inflammation of the liver
5 Viral Hepatitis HAV HBV HCV HDV or Hepatitis Delta HEV
3 Phases of Hepatitis Preicteric (Flu-like, n/v, diarrhea, constipation, mild RUQ pain, tenderness) Ictoric (5-10 days after, jaundice, pruritis, clay color stools, < preicteric symptoms) Posticteric or convalescent (> energy, < pain/GI symptoms, enzymes and bilirubin normal
Hepatitis A Referred to as Infectious Hepatitis Often in epidemics Fecal/oral route Comes from poor sanitation (can't work food) Shellfish! Not destroyed by detergents (Needs 195*F and Bleach) 6 mo apart 2 shot vaccine, so plan trips early Can get post treatme
Hepatitis B Transmitted by blood, body fluid Can carry, have no symptoms, and pass to others High risk (IV drug users, Multiple partners, Healthcare workers Vaccine is 3 dose Increased risk for liver cancer
Hepatitis C Primary cause of chronic hepatitis, cirrhosis, and liver cancer Often chronic (and/or cirrhosis) before diagnosed. Body fluids and blood (Iv drugs, blood products, needle stick) Acute disease usually asymptomatic (but symptoms may be mild/ nonspecific
Hepatitis D Infects people already infected with Hepatitis B Increases the severity of Hepatitis B Transmission (Blood, Body fluids)
Hepatitis E Rare Transmitted by fecal contamination of water Fatal in pregnant women
Other Hepatitis Fulminant (Rapid progression, Usually B and D together) Toxic (High meds, alcohol) Autoimmune (Against liver, causes inflammation)
Diagnostic Tests for Hepatitis > ALT, AST, and alkaline phosphate > Serum bilirubin Viral antigens and antibodies (carrier?) Liver Biopsy (rule out cancer, detect cirrhosis/hepatitis) Nursing care: immediate direct pressure, lie right side, monitor for bleeding, don’t cough or str
Nonsurgical Management of Hepatitis Physical rest Diet therapy High caloric meals Drug therapy includes: (Antiemetics: Zofran, Finergran) (Antiviral medications: Interferon Alpha, Peginterferon Alpha)
Hepatitis Teaching Points Immunization available for A and B Postexposure prophylaxis - exposed but your taking immunoglobin. Avoid sexual activity until antibiody titers are negative No alcohol or OTC drugs (some, like tylenol) Don’t share razors or toothbrush
Antiviral Treatment of Hepatitis Interferon alpha or long acting interferon both interfere with replication of the virus and decrease the viral load Helps reduce liver inflammation and fibrosis SubQ injections May cause: flu symptoms and depression Do not get pregnant while taking!!!
Cirrhosis End stage of chronic liver disease that is irreversible (liver failure) Liver tissue is gradually destroyed & replaced by fibrous scar tissue The scar disrupts the blood flow through the liver to the vena cava and portal hypertension develops
3 Types of Cirrhosis Alcoholic (End: alcoholic liver disease, fatty liver, malnutrition, most common) Posthepatic (chronic viral hepatitis, caused by any type of hepatitis, "non-alcoholic" fatty liver) Biliary (obstructed bile flow, retained bile damages/destroys liver)
Cirrhosis Symptoms Enlarged liver Dull ache in epigastric, RUQ Weight loss weakness anorexia Diarrhea or constipation Complications depend on the amount of damage sustained by the liver Spider Angiomas Palmar Erythema Edema Neuropathy Mental Changes
Cirrhosis Complications Portal hypertension Ascites Bleeding esophageal varices Coagulation defects Jaundice Portal-systemic encephalopathy Hepatorenal syndrome Spontaneous bacterial peritonitis
Cirrhosis Diagnostics Liver function tests (AST , ALT , alkaline phosphate) CBC with platelets Serum electrolytes Coagulation studies Bilirubin Serum albumin and ammonia Abdominal Ultrasound EGD or ERCP Liver Biopsy
Cirrhosis Medications Diuretic: Spironolactone (Aldactone), Furosemide (Lasix) Laxative: Lactulose (Chronulac) < ammonia Anti-infective: Neomycin sulfate, < ammonia prod. B-blocker Ferrous sulfate, folic acid Vitamin K (Sub Q) Oxazepam (not liver filtered, < anxiety/it
Treatments for Cirrhosis 2g Na, < fluid (edema/acites) Paracentesis (aspirate peritoneal cavity, void prior, HOB ^, I/O, client wt. pre/post, measure abd girth) Esophageal varices (Endoscopic variceal ligation, Endoscopic Sclerotherapy) Transjugular intrahepatic shunt Transpl
Management of Cirrhosis Potential Hemorrhage Drug therapy—possibly nonselective beta blocker Gastric intubation with lavage Esophagogastric balloon tamponade
Liver Cancer Higher incidences with alcoholic cirrhosis, Hep B and C Poor prognosis
Liver Cancer Manifestations Fatigue Weakness Anorexia Weight loss Malaise Poor appetite Jaundice Feeling of abdominal fullness Painful RUQ mass Manifestations of liver failure
Liver Trauma Blunt/penetrating trauma Disrupts hemodynamics (shock) Monitor: > abd pain, < BP, bruising, light headedness, change in vital signs, shortness of breath Dx with abd CT Surgery (exploration if bleeding) Fresh frozen plasma with clotting factors, plate
Pancreas Function Exocrine Function (Enzymes breaks down dietary protein, Amalayse breaks down starch, Lipase breaks down fats in to glycerol and fatty acids) Endocrine function (Glucogon and insulin production essential for metabolism of fats, carbohydrates, and protein)
Pancreatitis Inflammation of the pancreas Release of enzymes into the pancreatic tissue
Acute Pancreatitis Self-destruction of pancreas (autodigestion) Often self-limiting, can develop to necrotizing hemorrhagic pancreatitis Causes: gallstones, ETHO, surgical trama, toxins, contraceptions, steroids, genetics May recover completely, or have recurrent attac
Acute Pancreatitis Manifestations Sudden continuous severe epigastric/LUQ pain, may radiate to back Fatty meal, any meal, ETHO, sugars N/V, distention/rigidity, < bowel sounds, fever/jaundice Retroperitoneal bleed 3-6 days after: Turner’s (flank bruising), Cullen’s (umbilicus bruising)
Acute Pancreatitis Complications Intravascular volume depletion Acute Respiratory Distress Syndrome Pleural effusion Pancreatic necrosis Abscess DIC (Problem with clotting, Bleed freely) Peritonitis and paralytic ileus Multisystem Organ Failure
Chronic Pancreatitis Irreversible, leads to pancreatic insufficiency R/T alcoholism Insoluble proteins calcify, block pancreatic ducts, cause fibrosis of tissue Chronic obstruction Has remissions and exacerbations Leads to loss of exocrine and endocrine function
Chronic Pancreatitis Manifestations Continuous gnawing dullness with recurrent intense epigastric and LUQ pain, radiates to back Days to weeks Intervals between episodes become shorter Anorexia nausea vomiting weight loss Ascites Steatorrhea (Fatty stool) Dark urine
Chronic Pancreatitis Treatments Analgesics Insulin Nutrition Pancreatic enzyme supplement (Pancrelipase (Lipancreatin), enhances digestion of starches and fats; supplies enzymes protease, amylase, and lipase; promotes nutrition and decreases # of BMs) Acid reducers Surgery
Pancreatitis Diagnostics Amylase and Lipase Trypsin (<80 mcg/L) WBC Glucose Ultrasound CT/MRI Possible ERCP (endoscopic retrograde cholangiopancreatography – differentiates inflammation and fibrosis from carcinoma fiberoptic scope) Percutaneous fine needle biopsy
Pancreatic Cancer Manifestations Usually not detected until late Anorexia, weight loss, n/v, gas Dull epigastric pain Hepatomegly (liver enlargement) Head of the pancreas = clay color stool, dark urine Body of the pancreas = pain with eating or laying supine Palpable mass and asci
Pancreatic Cancer Risk Factors Smoking Obesiety High intake of fat Chronic pancreatitis Diabetes mellitus Cirrhosis
Pancreatic Cancer Treatment Partial pancreatetomy Whipple’s procedure (Removal of the head of pancreas, entire duodenum, distal 3rd of the stomach, portion of jejunum, & lower half of common bile duct; client in the intensive care setting; often requires chemo & radiation)
Postop care for Whipple Procedure NPO (NG tube, TPN) Blood sugars (insulin) Assess for hemorrhage and Turner’s/Cullen’s sign Monitor wound/drains Risk for fistula (abnormal openings) Assess BS and stool (lack may be bowel obstruction, peritonitis) Monitor for infection (^ HR, fever)
Created by: nimeggs