Transcript REIMBURSEMENT ISSUES - Healthcare Made Gorgeously Easy

Chapter 6
Care of the Patient with a
Gallbladder, Liver, Biliary Tract,
or Exocrine Pancreatic Disorder
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Laboratory and Diagnostic Examinations
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Serum bilirubin test
Liver enzyme tests
Serum protein test
Oral cholecystography (gallbladder series)
Intravenous cholangiography (IV cholangiogram)
Operative cholangiography
T-tube cholangiogram
Ultrasound of the liver, gallbladder, and biliary
system
• Gallbladder scanning
• Liver biopsy
• Liver scanning
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Cholangiogram
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Liver Biopsy
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Laboratory and Diagnostic Examinations
(continued)
• Blood ammonia
• Hepatitis virus studies
• Serum amylase test
• Urine amylase test
• Ultrasound of pancreas
• Computerized tomography of the abdomen
• Endoscopic retrograde cholangiopancreatography of
the pancreatic duct (ERCP)
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Ammonia Breakdown
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Bilirubin & Clinical Significance
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Bilirubin is a yellowish pigment found in bile, a fluid produced by the liver.
This article discusses the laboratory test done to measure bilirubin in the blood. Total and direct bilirubin are usually measured to screen for
or to monitor liver or gallbladder problems. Large amounts of bilirubin in the body can lead to jaundice.
A test may also be done to measure bilirubin in a urine sample. For information on that test, see: Bilirubin - urine.
How the Test is Performed
A blood sample is needed. For information on how this is done, see: Venipuncture .
The laboratory specialist spins the blood in a machine called a centrifuge, which separates the liquid part of the blood (serum) from the
cells. The bilirubin test is done on the serum.
How to Prepare for the Test
You should not eat or drink for at least 4 hours before the test. Your health care provider may instruct you to stop taking drugs that affect the
test.
Drugs that can increase bilirubin measurements include allopurinol, anabolic steroids, some antibiotics, antimalaria medications,
azathioprine, chlorpropamide, cholinergics, codeine, diuretics, epinephrine, meperidine, methotrexate, methyldopa, MAO inhibitors,
morphine, nicotinic acid, birth control pills, phenothiazines, quinidine, rifampin, steroids, sulfonamides, and theophylline.
Drugs that can decrease bilirubin measurements include barbiturates, caffeine, penicillin, and high-dose salicylates such as aspirin.
Why the Test is Performed
This test is useful in determining if a patient has liver disease or a blocked bile duct.
Bilirubin metabolism begins with the breakdown of red blood cells in many parts of the body. Red blood cells contain hemoglobin, which is
broken down to heme and globin. Heme is converted to bilirubin, which is then carried by albumin in the blood to the liver.
In the liver, most of the bilirubin is chemically attached to another molecule before it is released in the bile. This "conjugated" (attached)
bilirubin is called direct bilirubin; unconjugated bilirubin is called indirect bilirubin. Total serum bilirubin equals direct bilirubin plus
indirect bilirubin.
Conjugated bilirubin is released into the bile by the liver and stored in the gallbladder, or transferred directly to the small intestines.
Bilirubin is further broken down by bacteria in the intestines, and those breakdown products contribute to the color of the feces. A small
percentage of these breakdown compounds are taken in again by the body, and eventually appear in the urine.
Normal Results
Direct bilirubin: 0 to 0.3 mg/dL
Total bilirubin: 0.3 to 1.9 mg/dL
Note: mg/dL = milligrams per deciliter
Normal values may vary slightly from laboratory to laboratory.
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Disorders of the Liver, Biliary Tract,
Gallbladder, and Pancreas
• Cirrhosis
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Etiology/pathophysiology
• Chronic, degenerative disease of the liver
• Scar tissue restricts the flow of blood to the liver
• Types of cirrhosis
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Laennec’s cirrhosis
Postnecrotic cirrhosis
Primary biliary cirrhosis
Secondary biliary cirrhosis
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Dieased Livers (Cirrhosis)
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Disorders of the Liver, Biliary Tract,
Gallbladder, and Pancreas
• Cirrhosis (continued)
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Etiology/pathophysiology (continued)
• Alteration of liver function
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Reduced ability to metabolize albumin
Obstruction of portal vein
Increased pressure in veins that drain GI tract
• Complications
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Portal hypertension
Ascites
Esophageal varices
Hepatic encephalopathy
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The Portal System
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Disorders of the Liver, Biliary Tract,
Gallbladder, and Pancreas
• Cirrhosis (continued)
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Clinical manifestations/assessment
• Early stages
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Abdominal pain
Liver is firm and easy to palpate
• Late stages
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Dyspepsia
Changes in bowel habits
Nausea and vomiting
Gradual weight loss
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Disorders of the Liver, Biliary Tract,
Gallbladder, and Pancreas
• Cirrhosis (continued)
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Clinical manifestations/assessment (continued)
• Late stages (continued)
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Ascites
Enlarged spleen
Spider angiomas
Anemia
Bleeding tendencies
Epistaxis
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Disorders of the Liver, Biliary Tract,
Gallbladder, and Pancreas
• Cirrhosis (continued)
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Clinical manifestations/assessment (continued)
• Late stages (continued)
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Purpura
Hematuria
Bleeding gums
Jaundice
Disorientation
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Figure 6-2
(From Lewis, S.M., Heitkemper, M.M., Dirksen, S.R. [2004]. Medical-surgical nursing: assessment and
management of clinical problems. [6th ed.]. St. Louis: Mosby.)
Systemic clinical manifestations of liver cirrhosis.
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Disorders of the Liver, Biliary Tract,
Gallbladder, and Pancreas
• Cirrhosis (continued)
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Medical management/nursing interventions
• Eliminate the cause
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Alcohol
Hepatotoxins
Environmental exposure to harmful chemicals
• Antiemetics
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Benadryl and Dramamine
Contraindicated: Vistaril, compazine, and Atarax
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Disorders of the Liver, Biliary Tract,
Gallbladder, and Pancreas
• Cirrhosis (continued)
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Medical management/nursing interventions
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• Diet
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Well-balanced
High calorie
Moderate protein
Low fat
Low sodium
Supplemental vitamins and folic acid
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Disorders of the Liver, Biliary Tract,
Gallbladder, and Pancreas
• Cirrhosis (continued)
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Medical management/nursing interventions
(continued)
• Treatment of complications
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Ascites
o Bedrest
o Strict I&O
o Restrict fluids and sodium
o Diuretics: aldactone, Lasix, HCTZ
o Vitamins K, C, and folic acid supplements
o LeVeen peritoneal-jugular shunt
o Paracentesis
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Figure 6-3
(From Beare, P.G., Myers, J.L. [1998]. Adult health nursing. [3rd ed.]. St. Louis: Mosby.)
LeVeen continuous peritoneal jugular shunt.
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Disorders of the Liver, Biliary Tract,
Gallbladder, and Pancreas
• Cirrhosis (continued)
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Medical management/nursing interventions
(continued)
• Treatment of complications (continued)
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Ruptured esophageal varices
o Maintain airway; establish IV
o Vasopressin drip to control bleeding
o Sengstaken-Blakemore tube
o Endoscopic sclerotherapy
o Portacaval shunt
o Blood transfusion
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Senstaken-Blakemore Tube
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Disorders of the Liver, Biliary Tract,
Gallbladder, and Pancreas
• Cirrhosis (continued)
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Medical management/nursing interventions
(continued)
• Treatment of complications (continued)
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Hepatic encephalopathy
o Decrease protein in diet
o Avoid drugs which are detoxified by the liver
o Lactulose
o Neomycin
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Disorders of the Liver, Biliary Tract,
Gallbladder, and Pancreas
• Hepatitis
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Etiology/pathophysiology
• Inflammation of the liver resulting from several types of
viral agents or exposure to toxic substances
• Hepatitis A
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Most common
Oral-fecal transmission
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Disorders of the Liver, Biliary Tract,
Gallbladder, and Pancreas
• Hepatitis (continued)
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Etiology/pathophysiology (continued)
• Hepatitis B
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Transmission by contaminated serum; blood transfusion,
contaminated needles, dialysis, or direct contact with
infected body fluids
• Hepatitis C
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Transmitted through contaminated needles and blood
transfusions
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Disorders of the Liver, Biliary Tract,
Gallbladder, and Pancreas
• Hepatitis (continued)
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Etiology/pathophysiology (continued)
• Hepatitis D
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Co-infection with hepatitis B
• Hepatitis E
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Fecal contamination of water
Rare in the U.S.; usually in developing countries
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Disorders of the Liver, Biliary Tract,
Gallbladder, and Pancreas
• Hepatitis (continued)
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Clinical manifestations/assessment
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General malaise
Aching muscles
Photophobia
Headaches
Chills
Abdominal pain
Dyspepsia
Nausea
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Disorders of the Liver, Biliary Tract,
Gallbladder, and Pancreas
• Hepatitis (continued)
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Clinical manifestations/assessment (continued)
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Diarrhea/constipation
Pruritus
Hepatomegaly
Enlarged lymph nodes
Weight loss
Jaundice
Dark amber urine
Clay-colored stools
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Figure 6-5
(From Kamal, A., Brockelhurst, J.C. [1991]. Color atlas of geriatric medicine. [3rd ed.]. St. Louis: Mosby-Year
Book—Europe.)
Severe jaundice.
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Disorders of the Liver, Biliary Tract,
Gallbladder, and Pancreas
• Hepatitis (continued)
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Medical management/nursing interventions
• Treat symptoms
• Small, frequent meals
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Low fat, high carbohydrate
• IV fluids for dehydration
• Vitamin C, vitamin B-complex, vitamin K
• Avoid unnecessary medications, especially sedatives
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Disorders of the Liver, Biliary Tract,
Gallbladder, and Pancreas
• Hepatitis (continued)
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Medical management/nursing interventions
(continued)
• Gamma globulin or immune serum globulin
• Hepatitis B immune globulin (HBIG)
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Should be given to anyone exposed to hepatitis B
• Hepatitis B vaccine
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Should be given to people identified as high risk for
developing hepatitis B
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Disorders of the Liver, Biliary Tract,
Gallbladder, and Pancreas
• Liver abscesses
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Etiology/pathophysiology
• May be single or multiple
• Abscess forms in the liver due to an invading bacteria
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Disorders of the Liver, Biliary Tract,
Gallbladder, and Pancreas
• Liver abscesses (continued)
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Clinical manifestations/assessment
• Fever
• Chills
• Abdominal pain and tenderness in the right upper
quadrant
• Hepatomegaly
• Jaundice
• Anemia
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Liver Abcess
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Autopsy specimen showing a superior and an
inferior surface amoebic liver abscess.(Rt
.lobe)
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Disorders of the Liver, Biliary Tract,
Gallbladder, and Pancreas
• Liver abscesses (continued)
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Medical management/nursing interventions
• IV antibiotics
• Percutaneous drainage of liver abscess
• Open surgical drainage
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Disorders of the Liver, Biliary Tract,
Gallbladder, and Pancreas
• Cholecystitis and cholelithiasis
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Etiology/pathophysiology
• An obstruction, gallstone, or tumor prevents bile from
leaving the gallbladder and the trapped bile acts as an
irritant causing inflammation
• Risk factors
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Female; American Indian or white; obesity; pregnancy;
diabetes; multiparous women; use of birth control
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Figure 6-6
(From Phipps, W.J., Monahan, F.D., Sands, J.K., Marek, J.F., Neighbors, M. [2003]. Medical-surgical nursing:
health and illness perspectives. [7th ed.]. St. Louis: Mosby.)
Common sites of gallstones.
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Disorders of the Liver, Biliary Tract,
Gallbladder, and Pancreas
• Cholecystitis and cholelithiasis (continued)
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Clinical manifestations/assessment
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Indigestion after eating foods high in fat
Severe, colicky pain in the right upper quadrant
Anorexia
Nausea and vomiting
Flatulence
Increased heart and respiratory rates
Diaphoresis
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Disorders of the Liver, Biliary Tract,
Gallbladder, and Pancreas
• Cholecystitis and cholelithiasis (continued)
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Clinical manifestations/assessment (continued)
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Low-grade fever
Elevated WBC
Mild jaundice
Steatorrhea (fatty stool)
Dark amber urine
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Disorders of the Liver, Biliary Tract,
Gallbladder, and Pancreas
• Cholecystitis and cholelithiasis (continued)
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Medical management/nursing interventions
• Mild attacks
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Bedrest
NG tube to suction
NPO
IV fluids
Antispasmodic/analgesic
Antibiotics
Avoid spicy foods when allowed PO intake
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Disorders of the Liver, Biliary Tract,
Gallbladder, and Pancreas
• Cholecystitis and cholelithiasis (continued)
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Medical management/nursing interventions
(continued)
• Lithotripsy
• Cholecystectomy
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Laparoscopic
Open
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ESWL: Lithotripsy
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Cholecystectomy
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Disorders of the Liver, Biliary Tract,
Gallbladder, and Pancreas
• Pancreatitis
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Etiology/pathophysiology
• Inflammation of the pancreas
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Acute or chronic
• Predisposing factors
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Alcohol
Trauma
Infectious disease
Certain drugs
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Disorders of the Liver, Biliary Tract,
Gallbladder, and Pancreas
• Pancreatitis (continued)
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Clinical manifestations/assessment
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Abdominal pain
Anorexia; nausea and vomiting
Malaise
Low-grade fever
Jaundice
Weight loss
Steatorrhea
Tachycardia
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Disorders of the Liver, Biliary Tract,
Gallbladder, and Pancreas
• Pancreatitis (continued)
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Medical management/nursing interventions
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NPO
IV fluids
NG tube
Antiemetics
Demerol 75-100 mg every 3-4 hours
Anticholinergics
Antacids or Tagamet (prevent ulcers)
Hyperalimentation
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Disorders of the Liver, Biliary Tract,
Gallbladder, and Pancreas
• Cancer of the pancreas
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Etiology/pathophysiology
• Unknown
• Risk factors
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Cigarette smoking; exposure to chemical carcinogens;
diabetes mellitus; pancreatitis; diet high in meat, fat, and
coffee
• May be metastisis from the lung, stomach, duodenum,
or common bile duct (CBD)
• May live only 4-8 months after diagnosis
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Pancreatic Cancer
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Disorders of the Liver, Biliary Tract,
Gallbladder, and Pancreas
• Cancer of the pancreas (continued)
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Clinical manifestations/assessment
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Anorexia
Fatigue
Nausea and flatulence
Change in stools
Steady, dull, aching pain in the epigastric area
Weight loss
Jaundice
Onset of diabetes mellitus
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Disorders of the Liver, Biliary Tract,
Gallbladder, and Pancreas
• Cancer of the pancreas (continued)
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Medical management/nursing interventions
• Surgery
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Whipple procedure
Total pancreatectomy with resection of parts of the GI
tract
• Chemotherapy
• Radiation
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Figure 6-9
(From Lewis, S.M., Heitkemper, M.M., Dirksen, S.R. [2004]. Medical-surgical nursing: assessment and
management of clinical problems. [6th ed.]. St. Louis: Mosby.)
Whipple’s procedure, or radical pancreaticoduodenectomy.
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Nursing Process
• Nursing diagnoses
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Activity intolerance
Breathing pattern,
ineffective
Fluid volume, deficient
Home maintenance,
impaired
Injury, risk for
Knowledge, deficient
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Noncompliance
 Nutrition, imbalanced,
less than body
requirements
 Pain, acute/chronic
 Powerlessness
 Skin integrity, impaired
 Thought processes,
disturbed
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