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MedSurg II-Biliary Tract Disorders (ppt)

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cdunbar4's version from 2017-04-11 01:41

Etiology, Patho, Manis

Question Answer
Most common disorder of biliary systemcholelithiasis (stones in gallbladder)
Location of stoneslodged in the neck of the gallbladder or in the cystic duct.
What is cholecystitis?inflammation of gallbladder (usually assoc. with cholelithiasis) Could be acute or chronic.
Risk factorsfemale, multiparity, age >40yrs, estrogen therapy, sedentary lifestyle, genetics/ethnicity, obesity
How does obesity cause gallstones?increased secretion of cholesterol in bile
Oral contraceptives from women who are on estrogen therapy postmenopausal are at greater risk of gallstones, why?Oral contraceptives affect cholesterol production & increase the likelihood of gallbladder cholesterol saturation.
Ethnicities gallbladder disease is prevalent in.Asian & African Americans; esp. high in Native Populations
Etiology unknown. What is the pathophysiology?balance that keeps cholesterol, bile salts, and calcium in solution is altered, leading to precipitation-->bile is supersaturated with cholesterol-->stasis of bile-->supersaturation & changes in composition of bile (biliary sludge)-->immobility, pregnancy, inflammatory or obstructive lesions of biliary system↓ bile flow->stones remain in gallbladder or migrate to cystic duct
Acalculous cholecystitis Older adults and critically ill; Prolonged immobility, fasting, parenteral nutrition, diabetes; Bacteria or chemical irritants; Adhesions, neoplasms, anesthesia, opioids
Bacteria can reach gallbladder via vascular or lymphatic route. What types?E.coli, strep, salmonallae
Result of inflammation: where, characteristics, post-attack results?confined to mucous lining or entire wall; gallbladder edematous & hyperemic; can be distended w pus; cystic duct can get occluded; scarring & fibrosis after attack
Clinical manisPAIN when stones are moving or obstructing (steady, excruciating). Pt. gets tachy, diaphoretic, abd rigid, jaundice, n/v, prostration. Pain may refer to shoulder/scapula; residual tenderness in RUQ
When does pain usually occur?3-6 hours post high-fat meal or when patient lies down.
May or may not produce symptoms "silent cholelithiasis" could occur.
If inflammatory response is increased, what findings may be present?Leukocytosis, fever.
chronic cholelithiasishistory of fat intolerance, dyspepsia, heartburn, and flatulence.
Obstructive jaundice is caused by lack of bile flow into duodenum. Total obstruction symptoms?jaundice; dark amber urine (bilirubin in urine); clay-colored stools; pruritus (d/t deposition of bile salts in skin tissues; intolerance of fatty foods; bleeding (d/t lack of absorption of Vit K=> ↓prothrombin; steatorrhea (no bile salts in duodenum to emulsify & digest fats)
Complicaitonsgangrenous cholecystitis, subphrenic abscess, pancreatitis, cholangitis (inflammation of biliary ducts), biliary cirrhosis, fistulas, and rupture of the gallbladder, which can produce bile peritonitis.
In older patients and those with diabetesgangrenous cholecystitis and bile peritonitis are the most common complications of cholecystitis.
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Diagnostics, Collaborative Care

Question Answer
Common tool for diagnosis, esp. for pts with jaundice & pts allergic to contrast mediumUltrasonography, because it does not depend on liver function.
ERCPEndoscopic retrograde cholangiopancreatography
Benefits of ERCP for diagnosisallows for visualization of the gallbladder, cystic duct, common hepatic duct, and common bile duct. Bile taken during ERCP is sent for culture to identify possible infecting organisms.
Percutaneous transhepatic cholangiographyinsertion of a needle directly into the gallbladder duct, followed by injection of contrast materials. It is generally done after ultrasonography indicates a bile duct blockage.
Will the following labs be increased or decreased: WBC, serum bilirubin, urinary bilirubin, LFTs, serum amylase levels?all increased. Amylase is increased if the pancreas is involved.
Oral dissolution therapy if surgery is not an option...Bile salts: ursodeoxycholic acid (ursodiol [Actigall]) and chenodeoxycholic acid (chenodiol) are used to dissolve stones
Generally cholecystectomy is tx of choice because of success rateswith oral drugs, gallstones can reoccur
ERCP with sphincterotomyVisualization - Dilation - Placement of stents - Open the sphincter of Oddi, if needed - Endoscope passed to duodenum- Stones removed with basket or allowed to pass in stool
How does endoscopic sphinterotomy work?endoscope is advanced through the mouth and stomach until its tip sits in the duodenum opposite the common bile duct→. After widening the duct mouth by incising the sphincter muscle, the physician advances a basket attachment into the duct and snags the stone.
Extracorporeal shock-wave lithotripsy (ESWL) can be used if stones can't be removed via endoscopelithotriptor produces high-energy shock waves to disintegrate gallstones once they have been located by ultrasonography. It usually takes 1 to 2 hours for stones to disintegrate.
During an acute episode of cholecystitis, the focus of treatment is on:control of pain, control of possible infection with antibiotics, and maintenance of fluid and electrolyte balance.
Drugs used during acute episode of cholecystitisNSAIDs (e.g., ketorolac [Toradol]) are given for pain management.Anticholinergics to decrease secretion and counteract smooth muscle spasms may be administered.
When would a NG tube be necessary?if n/v is severe, can help with gastric decompression & to prevent further gallbladder stimulation
NTK Laproscopic cholecystectomy *tx of choiceA laparoscope, which has a camera attached, is inserted into the abdomen. (The incision sites may vary.) These punctures are used for insertion of the laparoscope and the grasping forceps. Using closed-circuit monitors to view the abdominal cavity, the surgeon retracts and dissects the gallbladder and removes it with grasping forceps. This is a safe procedure with minimal morbidity.
Benefits of laproscopic cholecystectomyMost patients have minimal postoperative pain and are discharged the day of surgery or the day after. They are usually able to resume normal activities and return to work within 1 week.
Open (incisional) cholecystectomy Removal of gallbladder through right subcostal incision and T-tube insertion ensures patency of the duct until the edema produced by the trauma of exploring and probing the duct has subsided.
transhepatic biliary catheter The catheter is inserted percutaneously and allows for decompression of obstructed extrahepatic bile ducts so that bile can flow freely. After insertion, the catheter is connected to a drainage bag. Used preoperatively in biliary obstruction and in hepatic dysfunction secondary to obstructive jaundice.
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Drugs & Nutritional Therapy

Question Answer
Most common drug classes used in the treatment of gallbladder diseaseanalgesics, anticholinergics (antispasmodics), fat-soluble vitamins, and bile salts.
AnalgesicsNSAIDS, morphine
Anticholinergicsatropine
fat-soluble vitaminsA, D, E, K
Administration of cholestyramine for pruritusGiven in powdered form, mixed with milk or juice. Monitor for side effects (nausea/vomiting, diarrhea or constipation, skin reactions)
Diet should be high infiber and calcium
Diet, what should be reduced?low in saturated fat and calories should be reduced if pt. is obese
Pt. should avoid what when dieting?rapid weight loss bc it can promote gallstone formation
Examples of saturated fatsbutter, shortening, lard
Nutritional therapy post laparoscopic cholecystectomyliquids first day; light meals for several days
Nutritional therapy post incisional cholecystectomyLiquids to regular diet after return of bowel sounds. May need to restrict fats for 4–6 weeks
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Nursing Management & Post-Op Care

Question Answer
past HHobesity, multiparity, infection, cancer, extensive fasting, pregnancy
medicationsuse of estrogen or oral contraceptives
Surgery or other treatments: previous abdominal surgery
Health-perception-health managementpositive family history; sedentary lifestyle
Nutritional-metabolicweight loss or anorexia; indigestion or fat intolerance; nausea and vomiting or dyspepsia; chills
Eliminationclay-colored stools, steatorrhea, flatulence, dark urine
Cognitive-perceptualmoderate to severe pain in right upper quadrant that may radiate to the back or scapula; pruritus
Objective Data: General, Integumentary, RespiratoryFever; Restlessness; Jaundice, icteric sclera; Diaphoresis; Tachypnea; Splinting
Objective Data: CV, GItachycardia, palpable gallbladder, abd guarding & distention
Possible dx findings: ↑ serum liver enzymes, alkaline phosphatase, and bilirubin levels; absence of urobilinogen in urine, ↑ urinary bilirubin level; leukocytosis, abnormal gallbladder ultrasound findings
Nursing Implementationrelieve pain, nv; provide comfort/emotional support; maintain fluid & elytes/nutrition; accurate assessments; monitor for complications
Pruritus relief measuresbaking soda or Alpha Keri baths; applying lotions containing calamine; antihistamines; soft or old linen; and control of the temperature (not too hot and not too cold). Keep the patient’s nails short and clean. Teach the patient to rub with the knuckles rather than scratch with the nails when he or she cannot resist scratching.
Post ERCP careAssessment to detect complications such as pancreatitis, perforation, infection, and bleeding. Monitor the patient’s vital signs. Abdominal pain and fever may indicate pancreatitis. The patient should be on bed rest for several hours and should be on NPO status until the gag reflex returns. Teach the patient the need for follow-up if the stent is to be removed or changed.
Post op laparoscopic caremonitoring for complications such as bleeding, making the patient comfortable, and preparing the patient for discharge.
Common post op lap chole problemreferred pain to the shoulder because of the carbon dioxide (CO2) that is used to inflate the abdominal cavity during surgery. It may not be released or absorbed by the body. The CO2 can irritate the phrenic nerve and the diaphragm, causing some difficulty in breathing.
Nursing Intervention for referred pain to shoulderPlacing the patient in the Sims’ position (left side with right knee flexed) helps move the gas pocket away from the diaphragm. Encourage deep breathing along with movement and ambulation. The pain can usually be relieved by NSAIDs or codeine.
Patient privilegesclear liquids, ambulate to bathroom, most pts go home same day
Post op car incisional cholefocuses on adequate ventilation and prevention of respiratory complications.
Ambulatory & home carediet is usually low in fat, and sometimes a weight-reduction diet is also recommended. The patient may need to take fat-soluble vitamin supplements. Provide instructions regarding observations that the patient should make that indicate obstruction (e.g., stool and urine changes, jaundice, pruritus). Explain the importance of continued health care follow-up.
Ambulatory & home care: lap choleRemove the bandages on the puncture site the day after surgery, and then you can shower. Notify your surgeon if any of the following signs and symptoms occur: Redness, swelling, bile-colored drainage or pus from any incision Severe abdominal pain, nausea, vomiting, fever, chills You can gradually resume normal activities. You can return to work within 1 week of surgery. You can resume your usual diet, but a low-fat diet is usually better tolerated for several weeks following surgery.
Ambulatory & home care: open-incision choleThe patient is usually discharged in 2 to 3 days. Instruct the patient to avoid heavy lifting for 4 to 6 weeks. Usual sexual activities, including intercourse, can be resumed as soon as the patient feels ready unless given other instructions by the health care provider.
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