Transcript REIMBURSEMENT ISSUES

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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Slide 2
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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Slide 3
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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Slide 4
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 construct albumin
Obstruction of portal vein
Increased pressure in veins that drain GI tract
• Complications
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Portal hypertension due to vein obstruction by cirrhosis
Ascites – excessive fluid and albumin in peritoneal cavity
Esophageal varices due to portal hypertension
Hepatic encephalopathy – ammonia intoxication causing
brain damage – check for flapping hands
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Slide 5
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’ anorexia, N/V,
Liver is firm and easy to palpate
• Late stages
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Dyspepsia;Changes in bowel habits
Nausea and vomiting
Jaundice and ecchymoses
Gradual weight loss
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Slide 6
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 –
o Epistaxis; Hematuria; Purpura; bleeding gums
Disorientation
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Slide 7
Figure 6-2
(From Lewis, S.M., Heitkemper, M.M., Dirksen, S.R. [2007]. Medical-surgical nursing: assessment and
management of clinical problems. [7th ed.]. St. Louis: Mosby.)
Systemic clinical manifestations of liver cirrhosis.
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Slide 8
Disorders of the Liver, Biliary Tract,
Gallbladder, and Pancreas
• Cirrhosis (continued)
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Medical management/nursing interventions
• Pharmacological management
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Antiemetics
o Benadryl and Dramamine
o Contraindicated: Vistaril, Compazine, and Atarax
• Eliminate the cause!
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Alcohol
Hepatotoxins
Environmental exposure to harmful chemicals
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Slide 9
Disorders of the Liver, Biliary Tract,
Gallbladder, and Pancreas
• Cirrhosis (continued)
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Medical management/nursing interventions
(continued)
• Diet
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Well-balanced
High in calories -2500-3000 cal
Moderate in protein 75G
Low in fat
Low in sodium 1-2 G
Supplemental vitamins (especially B group) and folic acid
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Slide 10
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 Bed rest
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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Slide 11
Figure 6-3 Decreases ascites
(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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Slide 12
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 transfusions
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Slide 13
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 that are detoxified by the liver
o *Lactulose – pulls ammonia from blood into bowel
and causes osmotic laxative effect
*http://www.nlm.nih.gov/medlineplus/druginfo/meds/a682338.html
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Neomycin – “causes a reduction in mucosal
glutaminase activity and thereby decreases the ability
of the mucosa to consume glutamine and produce
ammonia”. http://www.ncbi.nlm.nih.gov/pubmed/7741004
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Slide 14
Normal labs
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Total bilirubin: 0.3 to 1mg/dL
AST: 0-35 units/dL
ALT: 4-36 units/dL
Alkaline Phosphatase; 30-120 units/ dL
Albumin: 3.5 – 5 /dL
Total protein: 6.4 – 8.4 g/dL
Lipase: 10- 140 units/ L
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Slide 15
Disorders of the Liver, Biliary Tract,
Gallbladder, and Pancreas
• Liver cancer
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Etiology and pathology
• Hepatocellular carcinoma most commonly seen
• Cirrhosis of the liver and hepatitis C and B are also
elevated risk factors
• In the United States liver cancer is seen more in people
over age 40
• Metastatic carcinoma of the liver is seen more than
primary liver cancer due to high vascularity and blood
flow
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Slide 16
Disorders of the Liver, Biliary Tract,
Gallbladder, and Pancreas
• Liver cancer
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Clinical manifestations
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Hepatomegaly*
Weight loss*
Peripheral edema*
Ascites*
Portal hypertension*
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*also seen in cirrhosis
Dull epigastric pain
Jaundice (visible with bili level over 2.5mg/dL)
Anorexia, N/V
Extreme weakness
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Slide 17
Disorders of the Liver, Biliary Tract,
Gallbladder, and Pancreas
• Liver cancer
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Diagnostic tests
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Liver scan
Ultrasound
CT scan
Magnetic resonance imaging
ERCP
Liver biopsy – needle aspirate
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How do you position the patient to recover from a liver
biopsy?
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Slide 18
Disorders of the Liver, Biliary
Tract, Gallbladder, and Pancreas
• Liver cancer
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Medical management/nursing interventions
• Palliative care
• Surgery – excision or removal with transplant
• Chemotherapy - 5FU via hepatic artery or portal vein
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Slide 19
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
“A” for awfully dirty hands
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Slide 20
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
It “B” in the blood and body fluids
• Hepatitis C
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Transmitted through contaminated needles and blood
transfusions
“C” the needles with the blood on them
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Slide 21
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
“D’sex ain’t worth it”
• Hepatitis E
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Fecal contamination of water
Rare in the United States; usually in developing countries
“EWW” the water looks brown
• Hepatitis G
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“Gee” I don’t want transfusions from over there
****Reportable to CDC****
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Slide 22
Disorders of the Liver, Biliary Tract,
Gallbladder, and Pancreas
• Hepatitis (continued)
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Clinical manifestations/assessment
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May be asymptomatic
General malaise
Aching muscles
Photophobia
Headaches
Chills
Abdominal pain
Dyspepsia
Nausea
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Slide 23
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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Slide 24
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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Slide 25
Disorders of the Liver, Biliary Tract,
Gallbladder, and Pancreas
• Hepatitis (continued)
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Medical management/nursing interventions
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Hospitalization for bilirubin > 10mg/dl or inc. PT, INR
Treat symptoms
Bed rest
Small, frequent meals
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Low-fat, low protein and high-carbohydrate
NO ETOH
• IV fluids for dehydration
• Vitamin C, vitamin B–complex, vitamin K
• Avoid unnecessary medications, especially sedatives
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Slide 26
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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Slide 27
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 invading bacteria
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Slide 28
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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Slide 29
Disorders of the Liver, Biliary Tract,
Gallbladder, and Pancreas
• Liver abscesses (continued)
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Diagnostic tests
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Radiograph
Ultrasound
CT scan
Liver scan
Medical management/nursing interventions
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IV antibiotic therapy specific to organism
Percutaneous drainage of liver abscess
Open surgical drainage if abscess ruptures
Treatment is deemed proper if symptoms decrease
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Slide 30
Disorders of the Liver, Biliary
Tract, Gallbladder, and Pancreas
• Cholecystitis &
cholelithiasis
• Etiology/pathophysiology
An obstruction, gallstone, or
tumor keeps bile from
leaving the gallbladder, and
the trapped bile acts as an
irritant, causing edema
• Risk factors: Female;
American Indian or white;
obesity; pregnancy; diabetes;
multiparous women; use of birth
control
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Slide 31
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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Slide 32
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)
Clay colored stool – bile duct is blocked
Dark amber urine
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Slide 33
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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Pharmacological management
o Antispasmodic and analgesic medications
o Demerol (meperidine)
o Antibiotics
Bed rest
NG tube to suction
NPO
IV fluids
Dietary recommendations: Avoid spicy foods when
allowed PO intake; low fat
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Slide 34
Disorders of the Liver, Biliary Tract,
Gallbladder, and Pancreas
• Cholecystitis and cholelithiasis (continued)
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Medical management/nursing interventions
(continued)
• Lithotripsy – shock waves through water or a cushion to
pulverize the stone(s) to sizes that can be excreted
• Cholecystectomy
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Laparoscopic removal
Open – may need T-tubes if common bile duct is
edematous
May need to aspirate bile from gallbladder before it can
be removed
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Slide 35
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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Damage to the tract
Alcohol overuse
Trauma
Infectious disease
Certain drugs
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Slide 36
Disorders of the Liver, Biliary Tract,
Gallbladder, and Pancreas
• Pancreatitis (continued)
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Clinical manifestations/assessment
• Elevated lipase level (5-40 x normal)
• Abdominal pain – LUQ
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Relieved by fetal or forward leaning positions
Anorexia; nausea and vomiting
Malaise
Low-grade fever
Jaundice
Weight loss
Steatorrhea
Tachycardia
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Slide 37
Disorders of the Liver, Biliary Tract,
Gallbladder, and Pancreas
• Pancreatitis (continued)
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Medical management/nursing interventions
• Pharmacological management
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Antiemetics
Analgesics
Anticholinergics
Antacids
NPO – WHY?
IV fluids
NG tube
Hyperalimentation
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Slide 38
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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Risk increases with age
Cigarette smoking; exposure to chemical carcinogens;
diabetes mellitus; pancreatitis; diet high in meat, fat, and
coffee; obesity
• May be metastasis from the lung, stomach, duodenum,
or common bile duct (CBD)
• May live only 4 to 8 months after diagnosis
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Slide 39
Disorders of the Liver, Biliary Tract,
Gallbladder, and Pancreas
• Cancer of the pancreas (continued)
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Clinical manifestations/assessment
• Abdominal pain in 85% of patients – worse at night
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Steady, dull, aching pain in the epigastric area
Anorexia
Fatigue
Nausea and flatulence
Change in stools
Weight loss
Jaundice and pruritis
Onset of diabetes mellitus – 50%
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Slide 40
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
o Like Billroth 2 but pancreas is attached to middle of
jejunum and bile ducts are attached to end of jejunum
Total pancreatectomy with resection of parts of the GI
tract
• Chemotherapy
• Radiation
• Nerve block to celiac plexus nerve
 Prognosis is poor. 5 year survival is <10%
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Slide 41
Figure 6-9
(From Lewis, S.M., Heitkemper, M.M., Dirksen, S.R. [2007]. Medical-surgical nursing: assessment and
management of clinical problems. [7th ed.]. St. Louis: Mosby.)
Whipple’s procedure, or radical pancreaticoduodenectomy.
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Slide 42