ACCESSORY ORGANS OF THE DIGESTIVE SYSTEM

REVIEW OF ANATOMY AND PHYSIOLOGY ACCESSORY ORGANS OF THE DIGESTIVE SYSTEM: Liver Gall bladder and ductal system Pancreas

ACCESSORY ORGANS OF THE DIGESTIVE SYSTEM:

Liver

Gall bladder and ductal system

Pancreas

This is an in-situ photograph of the chest and abdominal contents. As can be seen, the liver is the largest parenchymal organ, lying just below the diaphragm. The right lobe (at the left in the photograph) is larger than the left lobe. The falciform ligament is the rough dividing line between the two lobes.

REVIEW OF ANATOMY AND PHYSIOLOGY LIVER Liver lobules Hepatic sinusoids (capillaries) lined with Kupffer cells Portal circulation – brings blood to the liver from : stomach, spleen, pancreas & intestines

LIVER

Liver lobules

Hepatic sinusoids (capillaries) lined with Kupffer cells

Portal circulation – brings blood to the liver from : stomach, spleen, pancreas & intestines

REVIEW OF ANATOMY AND PHYSIOLOGY FUNCTIONS OF THE LIVER: Carbohydrate metabolism Glycogenesis Glycogenolysis Gluconeogenesis Fat metabolism - ketogenesis Protein metabolism anabolism deamination urea formation Secretion of bile Detoxification Metabolism of vitamins A,D,K,B & Clotting factors, esp prothrombin

FUNCTIONS OF THE LIVER:

Carbohydrate metabolism

Glycogenesis

Glycogenolysis

Gluconeogenesis

Fat metabolism - ketogenesis

Protein metabolism

anabolism

deamination

urea formation

Secretion of bile

Detoxification

Metabolism of vitamins A,D,K,B &

Clotting factors, esp prothrombin

REVIEW OF ANATOMY AND PHYSIOLOGY FUNCTIONS OF THE BILIARY SYSTEM: Gallbladder – concentrate & store bile Ductal system – route for bile to reach the intestines Bile is formed in the liver & excreted into the hepatic duct Cystic duct drains the gallbladder Hepatic duct joins he cystic duct to form common bile duct . Sphincter of Oddi : relaxed, bile enters duodenum; contracted, bile stored in the gall bladder; controlled by cholecystokinin from duodenal mucosa

FUNCTIONS OF THE BILIARY SYSTEM:

Gallbladder – concentrate & store bile

Ductal system – route for bile to reach the intestines

Bile is formed in the liver & excreted into the hepatic duct

Cystic duct drains the gallbladder

Hepatic duct joins he cystic duct to form common bile duct .

Sphincter of Oddi : relaxed, bile enters duodenum; contracted, bile stored in the gall bladder; controlled by cholecystokinin from duodenal mucosa

REVIEW OF ANATOMY AND PHYSIOLOGY PACREAS: Head, Body Tail Pancreatic duct FUNCTIONS OF THE PANCREAS: Exocrine : trypsinogen, chymotrypsin, amylase, lipase Endocrine : islets of Langerhans: insulin and glucagon

PACREAS:

Head,

Body

Tail

Pancreatic duct

FUNCTIONS OF THE PANCREAS:

Exocrine : trypsinogen, chymotrypsin, amylase, lipase

Endocrine : islets of Langerhans: insulin and glucagon

CASE STUDY Sirius, 54 y.o., was brought by his family because of vomiting of blood. He’s drowsy, with VS of : 36 o , 110, 28, 80/60. He’s a chronic alcoholic; jaundiced & with big abdomen

Sirius, 54 y.o., was brought by his family because of vomiting of blood.

He’s drowsy, with VS of : 36 o , 110, 28, 80/60.

He’s a chronic alcoholic; jaundiced & with big abdomen

CASE STUDY What other assessment findings would you expect? What are your plans?

What other assessment findings would you expect?

What are your plans?

NURSING ASSESSMENT MANIFESTATIONS OF LIVER DISORDERS Jaundice Hemorrhage / bleeding problems Pruritus and itching Ascites Generalized Edema Intolerance of Sedation

MANIFESTATIONS OF LIVER DISORDERS

Jaundice

Hemorrhage / bleeding problems

Pruritus and itching

Ascites

Generalized Edema

Intolerance of Sedation

MANIFESTATIONS OF LIVER DISORDERS JAUNDICE CAUSES: Prehepatic – hemolysis Intrahepatic – liver parenchymal dse Poshepatic – obstruction of bile ducts

JAUNDICE

CAUSES:

Prehepatic – hemolysis

Intrahepatic – liver parenchymal dse

Poshepatic – obstruction of bile ducts

MANIFESTATIONS OF LIVER DISORDERS HEMORRHAGE Due to inadequate prothrombin & other clotting factors Management : Bile salts p.o., Vit K, p.o. & parenteral, use of small needle with injection, use of soft toothbrush, check urine and stool for blood.

HEMORRHAGE

Due to inadequate prothrombin & other clotting factors

Management :

Bile salts p.o.,

Vit K, p.o. & parenteral,

use of small needle with injection,

use of soft toothbrush,

check urine and stool for blood.

MANIFESTATIONS OF LIVER DISORDERS PRURITUS & ITCHING Caused by bile pigment deposited to skin Management: bathing with tepid water & use of oil-based lotion cholestyramine – binds with bile salts and facilitates excretion withfeces Use soft linen Short fingernails

PRURITUS & ITCHING

Caused by bile pigment deposited to skin

Management:

bathing with tepid water & use of oil-based lotion

cholestyramine – binds with bile salts and facilitates excretion withfeces

Use soft linen

Short fingernails

MANIFESTATIONS OF LIVER DISORDERS ASCITES Causes : portal hypertension decreased plasma colloid osmotic pressure hyperaldosteronism

ASCITES

Causes :

portal hypertension

decreased plasma colloid osmotic pressure

hyperaldosteronism

MANIFESTATIONS OF LIVER DISORDERS ASCITES Management : daily weight & abdominal girth low Na diet, fluid restriction, diuretics relieve symptoms from pressure of ascites : high fowler’s turning & positioning IV albumin, Paracentesis Peritoneovenous Shunt

ASCITES

Management :

daily weight & abdominal girth

low Na diet, fluid restriction, diuretics

relieve symptoms from pressure of ascites :

high fowler’s

turning & positioning

IV albumin,

Paracentesis

Peritoneovenous Shunt

MANIFESTATIONS OF LIVER DISORDERS GENERALIZED EDEMA Insufficient albumin INTOLERANCE OF SEDATION Most sedatives are metabolized in the liver except phenobarbital

GENERALIZED EDEMA

Insufficient albumin

INTOLERANCE OF SEDATION

Most sedatives are metabolized in the liver except phenobarbital

DISEASES OF THE LIVER HEPATITIS CIRRHOSIS CANCER OF THE LIVER

HEPATITIS

CIRRHOSIS

CANCER OF THE LIVER

HEPATITIS TYPES: Viral Hepatitis Toxic Hepatitis – exposure to hepatotoxin : carbon tetrachloride. Morphine, barbiturates

TYPES:

Viral Hepatitis

Toxic Hepatitis – exposure to hepatotoxin : carbon tetrachloride. Morphine, barbiturates

HEPATITIS Hepatitis A Infectious Fecal-oral route Hepatitis B Serum hepatitis Blood & body fluid transmission

Hepatitis A

Infectious

Fecal-oral route

Hepatitis B

Serum hepatitis

Blood & body fluid transmission

HEPATITIS DIAGNOSIS: Screening test for Hepatitis Liver function tests: SGOT Alkaline Phosphatase SGPT Imaging: Ultrasound

DIAGNOSIS:

Screening test for Hepatitis

Liver function tests:

SGOT

Alkaline Phosphatase

SGPT

Imaging: Ultrasound

Grossly, there are areas of necrosis and collapse of liver lobules seen here as ill-defined areas that are pale yellow. Such necrosis occurs with hepatitis.

HEPATITIS PLANNING & IMPLEMENTATION 1. Prevent spread of the disease. Hepatitis A Transmission : fecal-oral route Incubation period : 2-7 wks (virus in the blood & feces) Most infective 2 wks before onset of s/sx Enteric precautions Gloves when handling stools Handwashing

PLANNING & IMPLEMENTATION

1. Prevent spread of the disease.

Hepatitis A

Transmission : fecal-oral route

Incubation period : 2-7 wks (virus in the blood & feces)

Most infective 2 wks before onset of s/sx

Enteric precautions

Gloves when handling stools

Handwashing

HEPATITIS PLANNING & IMPLEMENTATION 1. Prevent spread of the disease. Hepatitis B Transmission : Blood & body fluid Exposed individuals : Hep B immunoglobulin, provides passive immunity High Risk Individuals : Hep B vaccine Those who handle blood Homosexual males IV drug users Hemodialysis patients 2. Obtain rest to promote liver regeneration

PLANNING & IMPLEMENTATION

1. Prevent spread of the disease.

Hepatitis B

Transmission : Blood & body fluid

Exposed individuals : Hep B immunoglobulin, provides passive immunity

High Risk Individuals : Hep B vaccine

Those who handle blood

Homosexual males

IV drug users

Hemodialysis patients

2. Obtain rest to promote liver regeneration

HEPATITIS PLANNING & IMPLEMENTATION 3. Nutrition : Well- balanced, high P, high C 4. Providing comfort measures 5. Administer medications : Antivirals Liver supplements

PLANNING & IMPLEMENTATION

3. Nutrition : Well- balanced, high P,

high C

4. Providing comfort measures

5. Administer medications :

Antivirals

Liver supplements

CIRRHOSIS END RESULT OF HEPATO-CELLULAR INJURY Parenchymal cell death Regeneration & scarring Diminished blood flow fibrosis Fatty degeneration Portal vein obstruction TYPES: Postnecrotic – post Hep B; macronodular Portal (Laenec’s) – alcoholism; micronodular Biliary – obstruction Cardiac – from portal hypertension

END RESULT OF HEPATO-CELLULAR INJURY

Parenchymal cell death

Regeneration & scarring

Diminished blood flow fibrosis

Fatty degeneration

Portal vein obstruction

TYPES:

Postnecrotic – post Hep B; macronodular

Portal (Laenec’s) – alcoholism; micronodular

Biliary – obstruction

Cardiac – from portal hypertension

CIRRHOSIS ASSESSMENT: Gastrointestinal System DUE TO METABOLIC CHANGES IN THE LIVER (P,C,F ) Anorexia Nausea & vomiting Weight loss Flatulence Fatigue ABDOMINAL PAIN HEPATOMEGALY ASCITES

ASSESSMENT:

Gastrointestinal System

DUE TO METABOLIC CHANGES IN THE LIVER (P,C,F )

Anorexia

Nausea & vomiting

Weight loss

Flatulence

Fatigue

ABDOMINAL PAIN

HEPATOMEGALY

ASCITES

Ongoing liver damage with liver cell necrosis followed by fibrosis and hepatocyte regeneration results in cirrhosis. This produces a nodular, firm liver. The nodules seen here are larger than 3 mm and, hence, this is an example of "macronodular" cirrhosis.

Mallory's hyaline is seen here, but there are also neutrophils, necrosis of hepatocytes, collagen deposition, and fatty change. These findings are typical for acute alcoholic hepatitis. Such inflammation can occur in a person with a history of alcoholism who goes on a drinking "binge" and consumes large quantities of alcohol over a short time.

CIRRHOSIS ASSESSMENT: Endocrine System THE LIVER IS UNABLE TO METABOLIZE HORMONES OF THE ADRENAL CORTEX, OVARIES, ESTROGEN AND TESTES AMENORRHEA GYNECOMASTIA LOSS OF PUBIC HAIR IMPOTENCE Hepato-Renal Syndrome RENAL FAILURE WITHOUT DISEASE

ASSESSMENT:

Endocrine System

THE LIVER IS UNABLE TO METABOLIZE HORMONES OF THE ADRENAL CORTEX, OVARIES, ESTROGEN AND TESTES

AMENORRHEA

GYNECOMASTIA

LOSS OF PUBIC HAIR

IMPOTENCE

Hepato-Renal Syndrome

RENAL FAILURE WITHOUT DISEASE

CIRRHOSIS ASSESSMENT: Other: JAUNDICE ICTERIC SCLERAE PRURITUS SPIDER ANGIOMA PALMAR ERYTHEMA MUSCLE ATROPHY PROLONGED EASY BRUISING LABS: LIVER FXN TESTS S. BILIRUBIN PROLONGED Prothrombin time DECREASED Serum Albumin DECREASED Hgb & Hct

ASSESSMENT:

Other:

JAUNDICE

ICTERIC SCLERAE

PRURITUS

SPIDER ANGIOMA

PALMAR ERYTHEMA

MUSCLE ATROPHY

PROLONGED

EASY BRUISING

LABS:

LIVER FXN TESTS

S. BILIRUBIN

PROLONGED Prothrombin time

DECREASED Serum Albumin

DECREASED Hgb & Hct

CIRRHOSIS - management Sufficient rest & comfort Measures to relieve pruritus Nutrition: high calorie, low to moderate P, high C, low fat,Vit A, B comp, C, D and K Monitor, prevent bleeding. Diuretics if with ascites Client teaching : avoid hepatotoxic drugs : opiates & sedatives, avoid alcohol

Sufficient rest & comfort

Measures to relieve pruritus

Nutrition: high calorie, low to moderate P, high C, low fat,Vit A, B comp, C, D and K

Monitor, prevent bleeding.

Diuretics if with ascites

Client teaching : avoid hepatotoxic drugs : opiates & sedatives, avoid alcohol

CIRRHOSIS COMPLICATONS: HEPATIC COMA PORTAL HPN ESOPHAGEAL VARICES

COMPLICATONS:

HEPATIC COMA

PORTAL HPN

ESOPHAGEAL VARICES

Submucosal veins in the esophagus become dilated. These are known as esophageal varices. Varices are seen here in the lower esophagus as linear blue dilated veins. There is hemorrhage around one of them. Such varices are easily eroded, leading to massive gastrointestinal hemorrhage.

One of the most common findings with portal hypertension is splenomegaly, as seen here. The spleen is enlarged from the normal 300 grams or less to between 500 and 1000 gm. Another finding here is the irregular pale tan plaques of collagen over the purple capsule known as "sugar icing" or "hyaline perisplenitis" which follows the splenomegaly and/or multiple episodes of peritonitis that are a common accompaniment to cirrhosis of the liver.

HEPATIC COMA DEGENERATIVE DISEASE OF THE BRAIN FROM LIVER FAILURE DUE TO INABILITY OF THE LIVER TO CONVERT AMMONIA TO UREA CHANGES IN PERSONALITY AND BEHAVIOR LETHARGY CONFUSION TREMORS STUPOR DIZZINESS COMA FETOR HEPATICUS – FRUITY ODOR BREATH SPIDER TELANGIECTASIA ELEVATED SERUM AMMONIA LEVELS

DEGENERATIVE DISEASE OF THE BRAIN FROM LIVER FAILURE

DUE TO INABILITY OF THE LIVER TO CONVERT AMMONIA TO UREA

CHANGES IN PERSONALITY AND BEHAVIOR

LETHARGY

CONFUSION

TREMORS

STUPOR

DIZZINESS

COMA

FETOR HEPATICUS – FRUITY ODOR BREATH

SPIDER TELANGIECTASIA

ELEVATED SERUM AMMONIA LEVELS

HEPATIC COMA MANAGEMENT: Neuro monitoring Diet : Restrict P, high C, with Vit K Administer: enema, cathartics LACTULOSE – conversion of ammonia to nonabsorbable ammonium intestinal antibiotics – NEOMYCIN Management for cirrhosis

MANAGEMENT:

Neuro monitoring

Diet : Restrict P, high C, with Vit K

Administer:

enema,

cathartics

LACTULOSE – conversion of ammonia to nonabsorbable ammonium

intestinal antibiotics – NEOMYCIN

Management for cirrhosis

ESOPHAGEAL VARICES DILATION OF THE VEINS OF THE ESOPHAGUS FROM PORTAL HYPERTENSION PORTAL HYPERTENSION – resistance to normal venous drainage of the liver into the portal vein MANAGEMENT: Iced normal saline lavage Blood transfusions Vitamin K Sengstaken Blakemore - 3 lumen Keep scissors at bedside Label each lumen IV vasopressin Surgery – shunting of blood to decompress varices Sclerotherapy Percutaneous embolization

DILATION OF THE VEINS OF THE ESOPHAGUS FROM PORTAL HYPERTENSION

PORTAL HYPERTENSION – resistance to normal venous drainage of the liver into the portal vein

MANAGEMENT:

Iced normal saline lavage

Blood transfusions

Vitamin K

Sengstaken Blakemore - 3 lumen

Keep scissors at bedside

Label each lumen

IV vasopressin

Surgery – shunting of blood to decompress varices

Sclerotherapy

Percutaneous embolization

CANCER OF THE LIVER Primary Secondary – liver is the most common site of CA mets

Primary

Secondary – liver is the most common site of CA mets

Here is an hepatocellular carcinoma. Such liver cancers arise in the setting of cirrhosis. Worldwide, viral hepatitis is the most common cause, but in the U.S., chronic alcoholism is the most common cause. The neoplasm is large and bulky and has a greenish cast because it contains bile. To the right of the main mass are smaller satellite nodules.

CANCER OF THE LIVER S/SX : Anorexia Weight loss Weakness abdominal fullness and bloating Abdominal pain MANAGEMENT – Total Hepatic Lobectomy RESECTION IS UP TO 90% OF THE ORGAN

S/SX :

Anorexia

Weight loss

Weakness

abdominal fullness and bloating

Abdominal pain

MANAGEMENT – Total Hepatic Lobectomy

RESECTION IS UP TO 90% OF THE ORGAN

DISEASES OF THE GALLBLADDER CHOLELITHIASIS CHOLECYSTITIS

CHOLELITHIASIS

CHOLECYSTITIS

CHOLELITHIASIS FORMATION OF GALLSTONES RISK FACTORS : 4 F’s : female, fat, forty, fertile Multiparous Oral contraceptives Cirrhosis Obesity Hyperlipidemia Total parenteral nutrition Bile stasis

FORMATION OF GALLSTONES

RISK FACTORS : 4 F’s : female, fat, forty, fertile

Multiparous

Oral contraceptives

Cirrhosis

Obesity

Hyperlipidemia

Total parenteral nutrition

Bile stasis

CHOLELITHIASIS PRECIPITANTS: Alteration in the concentration of lecithin, cholesterol, and bile salts Metabolic changes Cholecystitis Biliary stasis

PRECIPITANTS:

Alteration in the concentration of lecithin, cholesterol, and bile salts

Metabolic changes

Cholecystitis

Biliary stasis

PATHOPHYSIOLOGY Bile acids and lecithin decrease in bile The capacity to dissolve cholesterol is reduced Excess cholesterol precipitate as crystals GALLSTONES

CHOLELITHIASIS ASSESSMENT: Biliary colic: RUQ pain, usually postprandially Referred pain: R subscapular (BOA’S SIGN) Epigastric pain Nausea & vomiting Evidence of choledocholithiasis: Jaundice Clay-colored stools Hyperbilirubinemia Elevated alkaline phosphatase DIAGNOSIS : Ultrasound

ASSESSMENT:

Biliary colic:

RUQ pain, usually postprandially

Referred pain: R subscapular

(BOA’S SIGN)

Epigastric pain

Nausea & vomiting

Evidence of choledocholithiasis:

Jaundice

Clay-colored stools

Hyperbilirubinemia

Elevated alkaline phosphatase

DIAGNOSIS :

Ultrasound

CHOLELITHIASIS PLANNING & IMPLEMENTATION: MEDICAL INTERVENTION Low fat diet Prevent dehydration Medications: Smooth Muscle relaxants: reduce spasm of the duct & permit bile passage Papaverine Nitroglycerine NO Morphine! Bile acids – Chenodeoxycholic acid (CHENIX) and Ursodeoxycholic acid (ACTIGALL) :for clients who are poor risk for surgery; Toxic to the liver

PLANNING & IMPLEMENTATION:

MEDICAL INTERVENTION

Low fat diet

Prevent dehydration

Medications:

Smooth Muscle relaxants: reduce spasm of the duct & permit bile passage

Papaverine

Nitroglycerine

NO Morphine!

Bile acids – Chenodeoxycholic acid (CHENIX) and Ursodeoxycholic acid (ACTIGALL) :for clients who are poor risk for surgery; Toxic to the liver

CHOLELITHIASIS SURGICAL INTERVENTION Cholecystostomy – draining of the gallbladder Cholecystectomy – removal of the gallbladder Choledocholithotomy – removal of stones from the common bile duct Intraoperative Cholangiogram – dye in the bile duct thru the cystic duct, if with choledocholithiasis

SURGICAL INTERVENTION

Cholecystostomy – draining of the gallbladder

Cholecystectomy – removal of the gallbladder

Choledocholithotomy – removal of stones from the common bile duct

Intraoperative Cholangiogram – dye in the bile duct thru the cystic duct, if with choledocholithiasis

GALLBLADDER SURGERY PRE-OP NURSING CARE: Assure optimal health Instruct client over pre-operative plan

PRE-OP NURSING CARE:

Assure optimal health

Instruct client over pre-operative plan

GALLBLADDER SURGERY POST-OP NURSING CARE: Prevent complications Providing biliary drainage Preventing distention Manage pain – Fowler’s position Maintain nutrition Discharge planning & homecare – d/c after 7-10 days

POST-OP NURSING CARE:

Prevent complications

Providing biliary drainage

Preventing distention

Manage pain – Fowler’s position

Maintain nutrition

Discharge planning & homecare – d/c after 7-10 days

GALLBLADDER SURGERY COMPLICATIONS: Bleeding Cardiorespiratory Thrombophlebitis Wound Evisceration and Dehiscence

COMPLICATIONS:

Bleeding

Cardiorespiratory

Thrombophlebitis

Wound Evisceration and Dehiscence

GALLBLADDER SURGERY POST-OP NURSING CARE: Prevent complications Providing biliary drainage Preventing distention Manage pain – Fowler’s position Maintain nutrition Discharge planning & homecare – d/c after 7-10 days

POST-OP NURSING CARE:

Prevent complications

Providing biliary drainage

Preventing distention

Manage pain – Fowler’s position

Maintain nutrition

Discharge planning & homecare – d/c after 7-10 days

GALLBLADDER SURGERY BILIARY DRAINAGE: Bloody drainage – normal during 1 st 2 hrs Greenish brown drainage - after 2 hrs 400 ml in 1 st 24 hrs, 200 ml/24 hrs thereafter Placed above the bile duct to collect overflow drainage

BILIARY DRAINAGE:

Bloody drainage – normal during 1 st 2 hrs

Greenish brown drainage - after 2 hrs

400 ml in 1 st 24 hrs, 200 ml/24 hrs thereafter

Placed above the bile duct to collect overflow drainage

GALLBLADDER SURGERY BILIARY DRAINAGE: T tube stays for 6 wks to 6 mos before it is removed Color to urine & stool should be observed after removal of the tube Chills and fever is normal with clamping of T tube during healing period.

BILIARY DRAINAGE:

T tube stays for 6 wks to 6 mos before it is removed

Color to urine & stool should be observed after removal of the tube

Chills and fever is normal with clamping of T tube during healing period.

GALLBLADDER SURGERY POST-OP NURSING CARE: Prevent complications Providing biliary drainage Preventing distention Manage pain – Fowler’s position Nutrition - when biliary drainage is reestablished: Fat –restricted diet Discharge planning & homecare – d/c after 7-10 days

POST-OP NURSING CARE:

Prevent complications

Providing biliary drainage

Preventing distention

Manage pain – Fowler’s position

Nutrition - when biliary drainage is reestablished:

Fat –restricted diet

Discharge planning & homecare – d/c after 7-10 days

GALLBLADDER SURGERY PREVENTING DISTENTION: NGT until peristalsis returns Rectal tube – expulsion of flatus Enema – 3 rd day – peristalsis and release of flatus

PREVENTING DISTENTION:

NGT until peristalsis returns

Rectal tube – expulsion of flatus

Enema – 3 rd day – peristalsis and release of flatus

GALLBLADDER SURGERY POST-OP NURSING CARE: Prevent complications Providing biliary drainage Preventing distention Manage pain – Fowler’s position Nutrition - when biliary drainage is reestablished: Fat –restricted diet Discharge planning & homecare – d/c after 7-10 days

POST-OP NURSING CARE:

Prevent complications

Providing biliary drainage

Preventing distention

Manage pain – Fowler’s position

Nutrition - when biliary drainage is reestablished:

Fat –restricted diet

Discharge planning & homecare – d/c after 7-10 days

CHOLECYSTITIS CAUSES: Infection: Strep, Staph, E. coli, Typhoid Gall stones Sludge Biliary stasis S/SX: Intolerance to fatty foods Unrelenting RUQ pain & tenderness Referred pain : right subscapular, epigastric Nausea & vomiting MURPHY’S SIGN

CAUSES:

Infection: Strep, Staph, E. coli, Typhoid

Gall stones

Sludge

Biliary stasis

S/SX:

Intolerance to fatty foods

Unrelenting RUQ pain & tenderness

Referred pain : right subscapular, epigastric

Nausea & vomiting

MURPHY’S SIGN

CHOLECYSTITIS LABS: Increased WBC Increased serum amylase DIAGNOSIS: Utltrasound COMPLICATIONS: Abscess Perforation choledocholithiasis

LABS:

Increased WBC

Increased serum amylase

DIAGNOSIS:

Utltrasound

COMPLICATIONS:

Abscess

Perforation

choledocholithiasis

CHOLECYSTITIS MANAGEMENT IVF Antibiotic NG tube decompression Cholecystectomy

MANAGEMENT

IVF

Antibiotic

NG tube decompression

Cholecystectomy

DISEASES OF THE PANCREAS PANCREATITIS ACUTE CHRONIC CANCER OF THE PANCREAS

PANCREATITIS

ACUTE

CHRONIC

CANCER OF THE PANCREAS

INFLAMMATION EDEMA OBSTRUCTION OF PANCREATIC DUCT RUPTURE & RELEASE OF DIGESTIVE ENZYMES AUTOLYSIS OF PANCREATIC TISSUE NECROSIS PANCREATITIS

ACUTE PANCREATITIS PREDISPOSING FACTORS: Binge alcohol drinking Biliary tract disease Duodenal obstruction Infection Trauma Nutritional deficiency

PREDISPOSING FACTORS:

Binge alcohol drinking

Biliary tract disease

Duodenal obstruction

Infection

Trauma

Nutritional deficiency

CHRONIC PANCREATITIS PREDISPOSING FACTORS: Alcohol ingestion Gallbladder disease Autoimmune factors

PREDISPOSING FACTORS:

Alcohol ingestion

Gallbladder disease

Autoimmune factors

PANCREATITIS RELIEF OF PAIN: Demerol NO MORPHINE! DIET Avoid caffeine and alcohol Small frequent feeding of BLAND, easy digestable food PANCREATIC EXTRACTS Viokase/ Cotazym – facilitate digestion of fat-soluble vitamins

RELIEF OF PAIN:

Demerol

NO MORPHINE!

DIET

Avoid caffeine and alcohol

Small frequent feeding of BLAND, easy digestable food

PANCREATIC EXTRACTS

Viokase/ Cotazym – facilitate digestion of fat-soluble vitamins

CANCER OF THE PANCREAS S/SX: Anorexia Weight loss Weakness Nausea Late signs: pain, jaundice ascites, palpable mass SURGERY: Whipples Procedure: removal of the head of the pancreas, distal stomach, CBD & duodenum

S/SX:

Anorexia

Weight loss

Weakness

Nausea

Late signs: pain, jaundice ascites, palpable mass

SURGERY:

Whipples Procedure: removal of the head of the pancreas, distal stomach, CBD & duodenum

Which laboratory value would the nurse expect to find in a client as a result of liver failure? Decreased serum creatinine Decreased sodium Increased ammonia Increased calcium

Which laboratory value would the nurse expect to find in a client as a result of liver failure?

Decreased serum creatinine

Decreased sodium

Increased ammonia

Increased calcium

God Bless