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JUDITH K.

SANDS

objectives After studying this chapter, the learner should be able to:
1 Describe the etiology, epidemiology, and pathophysiology of cholelithiasis, cholecystitis, and can-
cer of the biliary tract.
2 Compare treatment alternatives for biliary tract disease.
3 Describe the nursing care needs of patients with disorders of the biliary system"
I 4 List the causes of acute and chronic pancreatitis.
5 Explain the pathophysiological basis for signs and symptoms of acute and chronic pancreatitis
and pancreatic tumors.
6 Discuss management approaches for acute and chronic pancreatitis.
7 Develop nursing diagnoses, patient outcomes, and plans of interventions for patients who have
acute or chronic pancreatitis or cancer of the pancreas or who have had pancreatic surgery.

Epidemiology
PROBLEMS OF THE GALLBLAOOER
Cholelithiasis is a common health problem in the United
The biliary system is affected by stones and obstruction, in- States. Stones affect about 10% of men and 15% of women
flammation and infection, and cancer. Gallbladder disor- older than 55 years of age. An estimated 20 to 25 million adults
ders are extremely common and affect millions of adults have gallstones, and 1 million new cases are diagnosed annu-
every year. ally.'9 Many, if not most, patients are asymptomatic, and it is
theorized that a large number of cases remain undiagnosed.
CHOLELlTHIASIS/CHOLECYSTITISI Ten percent of persons with gallstones develop symptoms
CHOLEOOCHOLITHIASIS within 5 years of diagnosis, and greater than 500,000 surgical
Etiology procedures are performed each year at an annual treatment
Gallstones can occur anywhere in the biliary tree. The term cost in excess of five billion dollars.16 These figures make
cholelithiasis refers to stone formation in the gallbladder and cholelithiasis and its associated disorders the most common
represents the most common biliary disorder. Either acute or and costly digestive disease. Cholelithiasis is two times more
chronic inflarnrnation, termed cholecystitis, can result, usually
precipitated by the presence of stones. When stones form in or research'~i,
migrate to the common bile duct the condition is termed
choledocholithiasis. Figure 42-1 illustrates common sites for Relerence: Everhart JE: Contributions 01 obesity and weight loss to gall-
stone disease, Ann Intern Med 119(10):1029-1035,1993.
gallstones.
Eighty percent of gallstones are composed of choles- Obesity and the process of rapid weight loss are typically
tereI. 19The remaining 20% are pigmented stones, which are identified as significant risk factors for the development
further classified as black or brown.'9 Although the precise of gallstone disease. This study involved a data review of
studies related to the prevalence of gallstone disease
etiology of gallstones is unknown, the basic component of
from 1966 to 1992. The data showed that obesity was a
supersaturation of the bile v,ith êholesterol is widely ac- strong risk factor for gallstones in women, particularly
cepted. Because most healthy individuals experience super- during periods of rapid weight loss. Between 10% and
saturation of the bile at various times without developing 25% of obese persons will develop gallstones within a
gallstones, it is clear that other factors are operational as few months of beginning a very low-calorie diet, with
well. Risk factors for gallstones have been well identified perhaps one third of the total becoming symptomatic.
and include various clinical states associated with changes The risk is less strong in men and most strong in persons
with the highest body mass index and most rapid weight
in cholesterol formation and excretion (Research Box). The
1055. Treatment with ursodeoxycholic acid (ursodiol) dur-
risk factors for cholesterol gallstones are listed in the Risk ing weight 1055 effectively prevented the development of
Factors Box on the next page. The development of pig- stones. The effect of various diets on the incidence of
mented stones is linked to disease states such as cirrhosis, stone formation was not explored.
hemolytic disease, and chronic small bowel disease.19

1373

1374 unit: viii Alterations in Digestion and Elimination

common in women, occurs most frequently in midclle-aged Eighty-five percent of ali stones are Iess than 2 cm in diameter.
and older persons, and affects American Indians, Mexican Most are found in the galibIadder, but it is estimated that 15%
Americans, and whites more frequently than African Ameri- to 60% of persons oIder than age 60 who undergo surgery for
cans and Asians, although the incidence in Asians is increasing. galistones also have stones in the common bile duct.8
Black pigmented stones form as the result of an increase in
Pathophysiology unconjugated bilirubin and calcium with a corresponding de-
Bile is primarily composed of water plus conjugated bilirubin, crease in bile salts. GalibIadder motility may also be impaired.
organic and inorganic ions, smali amounts of proteins, and Brown stones develop in the intra- and extrahepatic ducts and
three lipids-bile salts, lecithin, and cholesterol. When the are usualiy preceded by bacterial invasion.
balance of these three lipids remains intact, cholesterol is held Although most persons with gallstones are asymptomatic,
in solution. If the balance is upset, cholesterol can begin to choIecystitis can develop at any time, usualiy from a blockage
precipitate. Cholesterol gallstone formation is enhanced by of the cystic duct by the stone or from edema and spasm ini-
the production of a mucin glycoprotein, which traps choles- tiated by the presence or passage of the stone. In acute chole-
terol particles. Supersaturation of the bile with cholesterol cystitis the galibladder is enIarged and tense. A secondary bac-
also impairs gallbladder motility and contributes to stasis. terial infection can occur within several days and is the cause
Cholesterol stones are hard, white or yellow-brown in color, of most of the serious consequences of the disease.
radiolucent, and can be quite large (up to 4 cm). The stones Classic clinicaI manifestations of symptomatic galistones in-
most frequently occur in multipIes but can be solitary. The clude pain in the right upper quadrant (RUQ) of the abdomen,
process of stone formation is sIow. Stones are theorized which is described as severe and steady. The pain frequently ra-
to grow steadily for 2 to 3 years and then stabilize in size. diates to the right scapula or shoulder, has a sudden onset, and
persists for about 1 to 3 hours.8 It may awaken the patient at
night or be associated with the consumption of a large or high-
Small bile duct fat meal. Some patients experience nausea and vomiting and
may be febrile. Chills and fever are more likely with acute choIe-
cystitis. Patients are rareIy jaundiced. Bowel sounds may be ab-
sento Palpation of the RUQ causes a severe increase in pain and
temporary inspiratory arrest (Murphy's sign). The episode of
choIecystitis usualiy subsides in 1 to 4 days. Clinical manifesta-
tions of choIecystitis are summarized in Box 42-1.
The diagnosis of galistones is fairIy straightforward when
the classic symptoms are present. The diagnosis is more diffi-
cult when the symptoms are milder or reflect simply general
dyspepsia. It is estimated that up to 25% of patients with irri-
table bowel syndrome or peptic ulcer disease also have gali-
stones, and the exact etiology of the patient's symptoms needs
to be determined if possible.8 Researchers theorize that many
patients with "poor outcomes" after gallbladder surgery may
actualiy reflect situations where the gallbladder was not really
the source of the patient's dyspepsia.8•19

'.1.1
, If.M
. '""' -&
c;.~lnlCªh-n.'1J3Fl.1:;.f:.stªt.l "
..
ÇJl1S
i Cholecystitis
figo 42-1 Common sites of gallstones. Sudden onset pain in the RUO of the abdomen
Severe and steady in quality
Frequently radiates to the right scapula or shoulder
risk'act rs Persists for about 1 to 3 hours
May awaken the patient at night
Cholesterol Gallstones
May be associated with consumption of a large or
Obesity fatty meal
Middle age , Anorexia, nausea, and possibly vomiting
Pregnancy, multiparity, and the use of oral contra- Mild to moderate fever
ceptives Decreased or absent bowel sounds
Rapid weight loss (-5 pounds/wkl Acute abdominal enderness and a positive Murphy's
Hypercholesterolem ia, use of anticholesterol medications sign
Diseases of the ileum Elevated white blood cell count, slightly elevated serum
Gender (approximately twice as common in women) bilirubin and ai a 'ne phosphatase leveis

1 figo 42-2 The development of uncomplicated chole. Fig. gencler.with acute cholecystitis or to relieve in- fying cholelithiasis.8 Diagnostic tests Percutaneous drainage may be used as a primary treat- Ultrasonography is the primary diagnostic tool for identi. Laboratory tests include white blood cell count. . but Any additional diagnostic testing is performed to rule out since the gallbladder remains intact. move a stone. erating scope may be introduced by dilating the tract to re- serum bilirubin. It is rarely a cost-effective option. Multiple drug instillations are required over 12 to 24 hours. Extensive selection criteria limit the use of this treatment to a small II see' help unril jaundice or other complications develop. Radiolucencies cystitis. oral cholecystography may be performed (Fig. including follow-up drug therapy.1.. The treatment is only effec- tive when stones are less than 1.19 Medications Surgical management Oral dissolution therapy with ursodeoxycholic acid Cholecystectomy was first performed in Berlin in 1882 (Actigall) may be prescribed for patients who are poor and evolved into a procedure with excellent effectiveness and surgical risks or who refuse surgery.er wall that cause scarring. Parients with chronic disease often do not Germany and adapted to the treatment of gallstones. multiparity. which allows space for the reuptake of the cholesterol in the stones. Up to 50% of patients experience re- currences within 5 years._obesjty. (arrollVs) are caused by gallstones. = . Litho- tripsy uses shock waves to disintegrate the stones. flammation and infection before surgery. If the results of ultrasonography are in. stone fragments. The drainage tube conclusive. ment for patients . which makes the treatment labor intensive for the physician and extremely expensive. The procedure has good short-term results. The drug gradually extremely low associated morbidity and mortality. recurrence rates run as other causes of gastrointestinal (GI) discomfort. and the treatment. and liver function.:so e resem. alkaline phosphatases. . number of patients with gallstones. is placed percutaneously using sonographic guidance. high as 50%.:S ually the result of e Gallbladder Treatments and Exocrine Pancreas chapter42 1375 Extracorporeal shock wave lithotripsy was pioneered in I ::::e gal:. ibly cerarion..5 to 2 cm in diameter. An op- ure 42-3). pn~sence of other diseases) CholedodTOlithiasis I Asymptomatic.19 Direct dissolution therapy with methyl-tert-butyl ether is occasionally used in high-risk surgical patients.'. Bacterial infection may z. A full course of treatment takes from 1 to 3 years and is ex- tremely expensive. Iifestyle. figo 42-3 Oral cholecystogram.":erseveral acute at- 'C"er.19 Patients must also un- ure 42-2 shows the relationship between stone formation and dergo oral dissolution therapy after treatment to dissolve the associated outcomes in uncomplicated gallbladder disease. The drug is instilled through a percutaneous catheter. (Age. is tive times more expensive Collaborative Care Management than surgery. lt is the desaturates the bile. Etiological factor~:' . Recurrence is a problem.bla' . which is monitored fluoroscopically.

The patient is instructed to report the develop- Diet ment of redness. The CO2 is removed at the end of the pro.8 The main advantage of cholecystectomy is the fact that it stops the disease. catheters and nasogastric tubes are common1y inserted during bladder.16 Laparoscopic cholecystectomy offers several real ad. or tenderness in the abdomen. as No diet is known to prevent the formation of gallstones. however. patients with adequate home support may be discharged comes. swellin .pain. or choledocholithiasis. Patients will complete their preoperative preparation at duced.and by the early Referrals would not general1ybe required for the manage- 1990s had revolutionized the care of patients with gallbladder ment of uncomplicated gallstones unless a serious comor- disease. operative period. the procedure is usual1yattributable to inexperience with the technique. Dressings rapidly converted to an open cholecystectomy. Healthy The ski11of the surgeon is the primary determinant of out. Hospital stays av. and. lows a shorter healing and recuperation time. cholecystitis. CHOLECYSTECTOMY and the number continues to increase as surgical techniques improve. stones were present or suspected to be present in the common Preoperative teaching includes reviewing the scope and na- bile duct. Laparoscopic cholecystectomy was first performed in Referrals France in 1987and in the United States in 1988. Surgical techniques have continued to improve. unit. quire minimal care. he or she will cedure. After treatment they can resume a nor- standard against which other gallstone treatments are mea. and a laser or cautery is used to dissect the gall. Patients who are experiencing symptoms are encouraged to Heavy lifting should e a ·oided. midJine in the epi.1376 unit viii Alterations in Digestion and Elimination second most common surgical procedure performed in the follow a low-fat diet and eat sma11meals until definitive United States following cesarean section and serves as the therapy is completed. pain is mild to moderate and can be successfu11ymanaged Laparoscopic cholecystectomy is performed under general with standard analgesics.but the discomfort is easilymanaged with mild analgesics. The 3 days and consume a light diet. The incisions re- gas. clearly outweigh the higher surgical costs. over the small incisions are monitored for bleeding. The main dis. and pain control will receive priority atten- bon dioxide gas are introduced to insufflate the abdomen and tion. professionals. mal diet. and laparoscopic approaches are now being successfully provided in the immediate postoperative period.or discharge from any incision. tained gas pocket of CO2 away from the diaphragm and struments. When the laparoscopic cholecystectomy was first intro. The gallbladder is deflated and removed through the the procedure and will be removed in the postanesthesia care umbilical incision. The nurse combined with endoscopic exploration and sphincterotomyto also ensures that the patient understands that the expected effective1ytreat patients with common bile duct stones. it can be be encouraged to sip clear fluids and get out of bed. structed to slowly resume normal activity over the next 2 to dure. lithiasis. The patient is in- hospital stayand tremendous patient satisfactionwith the proce. home before their arrival on the day of surgery. in the right upper quadrant at the midclavicu. lf problems develop during the procedure. • PREOPERATIVE CARE tion. Laparoscopiccholecysteetomytakes about 90minutes Patient/Family Education and is more expensivethan traditional open surgery. sured. there is less scar- ring. . A left side-lying Sims position can he1p to move the re- permit adequate visualization and the introduction of in. It is conservative1y estimated that at least 80% of all UNDERGOING LAPAROSCOPIC cholecystectomies are being performed laparoscopically today. The hospital stay is less than NURSING MANAGEMENT 24 hours. bid condition necessitated the involvement of additional vantages over traditional surgery. and patients can return to normal activities in 2 to OF THE PATIENT 3 days. Activity advantage has always been that it is major abdominal surgery There are no activity restrictions for persons with chole- with a11of the associated pain and disability. we11as the onset of feyer. most important1y. As soon as the patient is sufficient1yalert. and at the anterior axillary line. and the dressings can usually be removed the next day. The patient is advised to mild shoulder pain that patients may experiencefor up to 1week limit the intake of fatty and fried foods for the first few weeks is attributed to nerve irritation from distention and the CO2 after surgery until tolerance is established. The procedure consists of the creation of four 1/2-inch incisions made at the umbilicus. • POSTOPERATIVE CARE gastric region. The operative field is magnified and projected on a decrease irritation. It is less invasive. eraged 3 to 7 days and recovery required 4 to 6 weeks. Deep breathing is encouraged.which al. The slight1yhigher rate ofbile duet injury associatedwith when they are fu11yalert and have successfu11yvoided. The patient will be close1ymonitored in the immediate post- lar line. how.The short Discharge instructions are straightforward. Three to 4 L of car. Foley videoscreen. The recurrence rate is zero. the ability to explore the common bile duct was limited. Acute infection is the only remaining contraindica. The nurse This limitation necessitated the use of open cholecystectomy will verify that the patient has had nothing by mouth procedures with placement of a T-tube for drainage whenever (NPO) and completed any required bowe1 preparation. anesthesia. the pain associated with the proceáure ís sígnífjcantIy reduced. ture of the surgi cal procedure and the care that will be ever.

some serous fluid and use of incentive spirometer because the high inci. Monitor color of urine and stools. or pulling of the tube. IV analgesic. Increase diet gradually to regular with fat content as toler- Explain the types of biliary drainage tubes that are ated (appetite and fat tolerance may be diminished if anticipated. Encourage use of incentive spi. if any. postanesthesiarecovery. check drainage on bandages q8hr. 1 to 2 hours) and to cough if secretions are present Explain to patient the importance of avoiding kinks. ditional open cholecystectomy. and right lower lobe pneumonia. Elderly persons may have substantially. Report any signs of peritonitis (abdominal pain. Thus they can develop baeterernia before they seek help. hemoglobin. rometer. white if bile is flowing out a drainage tube. or Use patient-controlled analgesia if possible.'. drainage is normal initially. then c1ear liquids. OK to shower surgery. assist to change po. Elderly patients have more risks with surgery just because of their age.clinicai pa1:hway . measure and record drainage at least every shift. PO analgesic sides. usually a drain is inserted Teach patient the importance of frequent deep breathing near the stump of the cystic duct. assess Disc 1&0.Hct. sition frequently. p.PAR. they I. sion and RUO pain predispose the patient to atelectasis Encourage progressive ambulation when permitted.i A ClinicaI Pathway for the patient undergoing laparoscopic cholecystectomy is shown below. Meperidine fever) to the physician immediately. there is externai biliary drainage). low fat vance to full liquids. urinalysis. Deepbreathing. 1378 for care of a T-tube. splint the incision. of the normal decrease in immune function with aging. Teach patient about the pain control plan to be used in the Biliary Drainage postoperative period. then q8hr. (Demerol) has been the drug of choice because it is be. The Guidelines for Care Box more subtle symptoms and signs in the presence of cholecystitis.Hgb. . Wound healing needs to be carefully monitored . mal color should gradually reappear as externai drainage diminishes and disappears. Assist patient to effectively clamping. Laparoscopíc Cholecystectomy Wíthout Complícatíons DAY OF SURGERY DAY OF ADMISSION DAY OF DISCHARGE DAY 1 DAY 2 Diagnostic Tests Preoperative: CSC. hematocrit. are at greater risk for septic shock.VS. Give analgesics fairly liberally the first 2 to 3 days. UA Postoperative: Hgb and Hct edications PAR: IVs decreased to saline lock after nausea sub. until ambulating well. Attach sufficient tubing 50 the patient can move without Urge patient to deep breathe at regular intervals (every restriction. . VS q4hr x 4. Monitor the amount and color of drainage frequently. low fat Activity Up in room with assistance about 6 to 10 hr after Up ad lib.vital signs. but the nor- phine is being used with increasing frequency. Postoperative See Figure 42-4 and the Guidelines for Care Box on Place patient in low Fowler's position. intact dressing. guidelines for care The Person Undergoing Open Cholecystectomy Preoperative Maintain a dry. assess bowel sounds bowel sounds q4hr.The laparoscopic GERONTOLOGICAL CONSIDERATIONS cholecystectomy procedure is particularly effective in this age- Gallbladder disease is seen more frequently with advancing age group as it decreases the period of immobility and recovery but is treated in the same manner.UA. then PO Treatments PAR: 1&0 q shift. remove bandages and reapply q2hr bandages after shower if necessary Diet NPO until nausea subsides. Disc saline lock. Connect any biliary drainage tubes to closed gravity drainage. Regular diet. ad. stools will be grayish- lieved to minimize spasms in the bile ducts. II Management of Persons with Problems of the Gallbladder and Exocrine Pancreas chapter42 1377 . but mor. VS q8hr. rigidity. Because II summarizes the care provided to a patient who undergoes tra. T & OS q2hr Consultations 08.

cholangitis (PSC). Zinc oxide may be used to protect the skin from irritation. When no cause for the bile duct injury can and visibility. Initial drainage may be as much as 500 to 1000 ml per day. the process is called idiopathic or primary sclerosing T-tube in place (see Figure 42-4). including over- surgery. Unclamp the tube promptly if distress occurs. Stool is initially clay- colored but regains pigmentation as bile again flows into the duodenum. Elderly patients may need some additional as. clinical malabsorption are often included as possible compli- tine monitoring of wound healing and the progressive return cations of cholecystectomy. whelming sepsis and peritonitis. .1378 unit viii Alterations in Digestion and Elimination SPECIAL ENVIRONMENTS FOR CARE sistance at home when they undergo same-day surgery.17 For more complex procedures patients that the reduction in the pool of bile salts and the loss of the may be discharged from the hospital with a T-tube in place.be anticipated for any phase of routine gallstone management. Check drainage every 2 hours on the first day ànd at least once per shift on subsequent days. The most com- mon complication of nonsurgical management of gallstone Home Care Management disease is recurrence. COMPLlCATIONS dures have an excellent safety record and are associated with a Transient mild diarrhea is the only adverse outcome that has less than 7% incidence of morbidity from any cause. or drainage from the site and the figo 42-4 Section o' T. A sterile dressing should be reapplied to the T-tube entry site each day. swelling. Some researchers suggest that these so-called "complica- tions" may actually reflect situations in which the patient's original digestive symptoms were never related to the gall- stones and therefore were not improved by their rem oval 'guide'ines for care (Research BOX). Record output carefully. Critical care management would not . Provide self-care teaching: A daily shower is usually permitted. and it is clear that undiagnosed or in- Cholecystectomy is the foundation of care for gallstones. Teach the patient to empty the bag and convert it to a leg bag if discharge with the T-tube is planned. been consistently linked to cholecystectomy. Redness.16 for Care Box. General Care Attach the tube to gravity drainage. Keep the skin clean and protected from bile drainage as bile is extremely irritating to the skin.5 Managing a T-Tube Purpose PRIMARY SCLEROSING CHOLANGITIS A T-tube may be placed after surgical exploration of the Etiology/Epidemiology common bile duct to preserve patency of the common Inflammation and scarring of the biliary tree occur most com- duct and ensure drainage of bile until edema resolves monlyas a result of gallstones and bile duct infection. but this amount should steadily decrease as healing occurs. but there is no concrete evidence to usual activities. Monitor patient's response to c1amping and record in- cidence of distress. Parasites and bile is effectively draining into the duodenum.ube emerging from stab development of fever should be promptly reported vvound may be placed over roll of gauze anchored to the physician. Monitor the color of the stool. The are a common source of chronic duct infection in Asia and de- tube is usually connected to gravity drainage and can be converted to a leg bag to limit its restrictiveness veloping countries. These Criticai Care Management needs are ideally identified and arranged before surgery. reservoir funetion of the gallbladder increase the incidence Teaching concerning T-tube care is included in the Guidelines of duodenal reflux or an alkaline shift in the gastric pH. Self-care management at home is therefore expected. to skin vvith adhesive spe to prevent its lumen from being occluded b p'essure. The patient may be discharged with the be found. and adequately treated gallbladder disease can result in serio the procedure has become essentially same-day or overnight and even life-threatening complications. Follow physician's order for initiating clamping of the tube. Ensure that suffi- cient tubing is in place to prevent pulling and restric- tion of movement. Chronic dyspepsia and sub- Most patients have no specific home care needs beyond rou. The surgical proce.

Drug therapy is aimed at reducing biliary tree infiarnma- Pathophysiology tion and preventing the scarring that leads to obstruction. Use tepid water for bathing rather than hot. The closest link is with inflammatory bowel dis. typically by the age of 45. Others are characteristics. stones (acalculous cholecystitis). documented gallstones before surgery. the eventual need for liver transplant. Liver biopsy shows tubes is ongoing but primarily in the form of clinicai trials. fever. and Liver transplantation is the primary treatment option. and intra. regularly. the combination of inflammation. Thirlby RC. ally male. alter the outcomes. fibrosis. laparoscopic cholecystectomy. PSC is the cause for about one third but timely intervention with a liver transplant can significantly of all patients needing liver transplantation. relieve obstruction. and the development of complications related to cirrhosis. only relieved in 52% of those without documented gall. and intolerance to fatty foods.Lonborg R.. Persistent jaundice may ticularly difficult aspect of the disease. effective. but the use of ursodeoxycholic acid has shown and extrahepatic fibrosis. abdominal its possible outcomes and are prepared for the possibility of pain. 91% experienced Apply emollient creams and lotions to dry skin biliary-related pain. And. mately 44% of the patients. e. Experiment with treatments sueh as oatmeal baths. and PSC is diagnosed in early or middle adulthood. A low-fat diet is recommended to patients who bilirubin levels. Both genetic and im. The aggressiveness of the patients with IBDY The PSC may precede the diagnosis of disease is influenced by the number and severity of infections IBD or follow it from 1 to 20 years late r.Traverso LW: What guide'ines for care symptoms does cholecystectomy cure? Am J Surg 16(5):533-538. study results showed that documented gallstone-related Avoid activities that increase body temperature or cause pain was universally relieved by surgery. 70% have IBD. Eighty-two per. The disease proceeds in stages. duetal obliteration that confirms the presence of the disease. particularly ulcerative colitis. indigestion. Patients are instructed about the disease and seen with a combination of fatigue. . obstruction. cholangiopancreatography (ERCP) (Chapter 38) is used to vi- The disease may occur alone but is generally associated with sualize the biliary tree. gloves at night to minimize skin damage from surgery only relieved the related symptoms in approxi. ease (IBD). and the fat research~~ Reference: Fenster LF. These strictures are short and diffusely dis. and 77% had both. or sepsis. cent also experienced related GI symptoms. Strictures can usually be found in promise even though its mechanism of action in PSC remains multiple locations. most of which have a strong immunological of the symptoms and assists in estimating the severity of the component. dilate ducts. Possible strategies are summarized in the Guidelines dyspepsia. Liver biopsy helps rule out other causes other disorders. do not rub.g. gas. although PSC only occurs in 2% to 4% of all which can be highly unpredictable. proliferation. negatively affect body image. biliary cirrhosis Patient/fami/y education is present (Chapter 37). Surgical procedures other than transplant have tributed and alternate with normal or dilated segments of the been effective for diffuse disease. Eighty-two percent had Pat skin dry after bathing or showering. cholecystectomy in relieving presenting GI problems. Strategies to Control Pruritis This study attempted to evaluate the effectiveness of Avoid irritating clothing (wool or restrictive clothing). and chronic severe pruritis can ence recurrent attacks of cholangitis. anagement of Persons vvith Problems of the Gallbladder and Exocrine Pancreas chapf:er42 1379 The prevalence of PSC is unknown. 1995. be a daily nightmare. jaundice. unknown. It is unusual for move stones. and by stage 4. Of patients with PSC The prognosis of PSC largely depends on its clinicai course. Primary sclerosing cholangitis causes changes in and around Steroids and other immunosuppressive agents have not been the large bile ducts from inflammation. seratehing. The nurse also suggests that the patient The diagnosis of PSC is not easily established and is usually experiment with common interventions that may lessen itch- made as part of a workup for cholecystitis or general nonulcer ing. and place stent the gallbladder or cystic duct to be involved. The amounts of humidity in the air. PSC causes elevated liver enzymes and serum for Care Box. The patients are usu. Use antipruritie medieations as ordered. although nonpain Keep the fingernails short and eonsider use of cotton symptoms were extremely common in this population. bleeding. Endoscopic retrograde munological mechanisms are suspected in its development. Maintain a cool environment and ensure adequate ing. and weight loss.23 Survival is typically about 10 years. liver damage. bloat. Some patients respond to cholestyr- amine resin. Patients may experi. making the diagnosis complexo The uncertain nature of PSC is one of its most difticult Many patients are asymptomatic in early stages. Data were colleeted from 225 patients who underwent Experiment with nonirritating soaps and detergents. considered to be a hallmark feature. Endoscopic treatment to re- ducts to create a beadlike appearance on x-ray. which theoretically binds the itch-triggering Collaborative Care Management elements in the bile. Persistent severe pruritis can be a par. but pain was sweating. Death is usually the result of liver failure. but the elevations in alkaline phosphatase are develop problems with diarrhea or steatorrhea.

How Treatment of bile duct cancer focuses on maintaining bile the obstruction activates the pancreatic enzymes is not under- flow. Biliary pancreatitis begins acutely. Fat-soluble PROBLEMS OF THE PANCREAS vitamin replacement is often needed. It Pat:ient:/family educat:ion is theorized that the various forms of obstruction can reverse Nursing intervention is focused on asslstmg the pa. not have to be prolonged to initiate acute inflammation. the normal pancreatic pressure gradient. vomiting. structural abnormalities that lead to narrowing at the sphinc- ter of Oddi can be considered a cause of biliary pancreatitis. tis is well recognized clinically but remains poorly explained. Alcoholic the time gallbladder cancer produces symptoms it is usually patients also typically develop chronic disease once an acute incurable. It is also mon symptom. drug effects. It demonstrates a striking link with the presence of in. Anorexia. in se- poor prognosis. sion. Surgery may be used to divert bile flow to the jejunum. through the lymphatics. obstruetion of the gland by neoplastic of age.23 By atitis in the organ before the first acute episode. The patient may have a pal. This would permit tient to self-manage the symptoms and possibly care for reflux of bile or duodenal contents into the pancreatic ducts bile drainage systems (see the Guidelines for Care Box on p. cal practice. weight loss.23 High-risk groups for gallbladder cohol abuse. which again increases the susceptibility of the pancreas to in- pable abdominal mass. Pathophysiology Alcoho/-re/ated pancreatitis Carcinoma can occur anywhere in the biliary system. creas in selected persons. When bile flow can be maintained. small pancreatic ducts or both.1I Other rare causes of pancreatitis include abdominal process also typically affects patients between 50 and 70 years or surgical trauma. Biliary pancreatitis tomy with wedge resection of 3 to 5 cm of normal liver plus Transient obstruction of the ampulla ofVater by a gallstone lymph no de dissection is usually performed. and jaundice may also be present. a variety of infectious diseases. tiate the processo Alcohol also weakens cell membranes and Intermittent pain in the upper abdomen is the most com. but it represents a different pathological Cancer can also develop in the bile ducts. is be- tency. chronic pancreatitis. nausea. This disease process. The remainder of care and teaching is generally sup. ACUTE PANCREATITIS CARCINOMA OF THE BILlARY SYSTEM Etiology Etiology/Epidemiology Acute pancreatitis occurs when obstruction of the outflow of Primary tumors of the gallbladder are extremely rare in clini. but is likely to be mild in portive as the patient and family face an uncertain haure and course and followed by rapid recovery. stood. It can.1I 1378). . pancreatic secretions triggers acute inflammation in the gland. and possibly even cause small duct rupture. The ocrine and endocrine cells and can involve either the large or etiology is unknown. Signs and symptoms indica tive of jury. patients may live for lieved to play a role. Cholecystec. however.1380 unit viii Alterations in Digestion and Elimination restriction usually prompt1y corrects the problem. and through the blood. Gallbladder cancer occurs almost ex. sludge) toa small to be identified by imaging studies. to death. Others have symptoms similar to those seen with zymatic abnormality. General care of the cancer patient is discussed lected situations trigger rnassive pancreatic necrosis and lead in Chapter 11. cases. It rarely leads to cnronic disease. Alcohol is believed to initiate an asymptomatic pancre- metastasis to the liver or pancreas may also be present. It has The role of alcohol in the development of acute pancreati- a very insidious onset and can metastasize by direct exten. Most Alcohol is presumed to have a direct toxic effect on the pan- patients have no symptoms that are referable to the gall. There is also considerable evidence that several years after diagnosis. it may be confined to the gallbladder and be curable with surgery. Stones those with invasive disease is usually less than 2 years. and their incidence may be declining beca use The obstruction can progress to necrosis of the pancreatic ex- of prompt surgical intervention for gallbladder disease. The presence of tiny gallstones (microlithiasis or biliary or stent tubes may be placed to attempt to maintain duct pa. and other flammatory bowel disease. The obstruction does outcomes. growth.12·21. pancreatitis are common. The two major causes of acute clusively in persons older than 60 years of age and is twice pancreatitis in the United States are gallbladder disease and al- as common in women. chronic diseases of the GI tract."·23 Together they account for about 80% of all disease in general have a slightly increased risk of gallblad. episode has occurred. der. If the disease is diagnosed incidentally. Extensive amounts of aIcohol over a cholelithiasis and cholecystitis because of obstruction and minimum period of several years are probably required to ini- inflammation. Acute pancreatitis may be similar in presentation to der canceI. and the presence of chronic pancreati- tis appears to make the pancreas even more vulnerable to the Collaborative Care Management damaging effects of alcohol. Survival for is considered to be a major cause ofbiliary pancreatitis. known to decrease the amount of trypsin inhibitor available. probably through some genetic en- bladder. Neither were found in the stool of more than 90% of patients with radiotherapy nor chemotherapy has thus far improved patient gallstone pancreatitis in some studies.23Recurrent episodes of acute Surgery is the primary treatrnent for cancer of the gallblad. makes the acinar cells more vulnerable to injury.

Activation of the pancreatic Acute pancreatitis may take a mild. . soponificotíon oF calcium figo 42-5 Summary of major pathological events that occur in acute pancreatitis. Ihterper-itoneol. and ab- The incidence of acute pancreatitis has increased in recent scesses and infection form in areas of walled off necrotic tis- years. but this increase may represent improved diagnostic ca. the interstitial form vascular permeability and vasodilation is often a mi!der disease. There are minimal or no areas of nated intravascular coagulation hemorrhage or necrosis in the gland. nual incidence is estimated to be 0. . Patients with biliary pancreatitis are likely to be 55 to the proteolytic enzymes. shock. be- with alcohol-related pancreatitis are usually slightly younger cause once trypsinogen is activated to trypsin it can then acti- and predominantly male. The current an. Management of Persons with Problems of the Gallbladder and Exocrine Pancreas chapter42 1381 Epidemiology ecrosis of vessels can cause significant loss of blood. sue. which retains its • Initiation of consumptive coagulopathy. Other systemic effects of the activated enzymes include: the (1) acute interstitial form and (2) acute hemorrhagic • Activation of complement and kinin. Systemic complications such as fat emboli. and 20% to 60% of these patients tery of acute pancreatitis is how that pathological sequence is will either die or face potentially lethal complications. but they fai! to fully explain the disease despite improved diagnosis and more aggressive treatment. Pancreatic juice normally contains only inactive forms of ulation.22 Enzyme activation overwhelms all of the normal protective mechanisms of the pancreas and initiates a massive Pathophysiology attack on the pancreatic tissues. The etiológical roles of alcohol and bi!iary disease overall mortality rate for pancreatitis remains at about 10% have been discussed. producing increased formoAlthough either form can be fatal. and the ducts which leads to circulatory insufficiency may contain purulent material. Pancreatitis has a fulminant course in approximately ognized as a major component of the diseaseprocessoThe mys- 5% to 15% of all patients.23 occur in acute pancreatitis . Pancreatic autodigestion is ini- The two major pathological varieties of acute pancreatitis are tiated. renal function in conjunction with circulatory insufficiency minant disease. Extensive fat necrosis is present in patients with ful.6 The initiated. • Increased stickiness of the inflammatory leukoeytes with The defining characteristic of acute interstitial pancreatitis the formation of emboli. which impairs necrosis. The gland readily promises cardiac function shows acute inflammation. hemorrhage. which further com- ease presents with a very different picture. process. and marked tissue • Activation of the renin-angiotension network.5 cases per 1000pop. The acute hemorrhagic dis. whereas patients hibitor specifically to prevent activation within the gland. hypotension. • Releaseof myocardial depressant factor. pabilities rather than a true increase in cases. which plug the microvasculature is a diffusely swollen and inflamed pancreas.1 to 0. vate the other enzymes as well. or fulminant enzymes before they reach the duodenum has long been rec- course. leading to dissemi- normal anatomic features. The pancreas secretes a trypsin in- 65 years of age and predominantly female. The interstitial spaces • Increased permeability causing massive movement of fluids. not just in the pancreas but throughout the Figure 42-5 outlines the major pathological events that can abdominal and thoracic cavities and subcutaneous tissues. and fluid overload are common. severe. become grossly swollen by extracellular edema.

Collaborative Care Management what according to the severity of the attack. L"" l_. . I." Morphine. CT scans can estimate the size of the '.I.l~nJ.. tions are exclusive to pancreatic disease.3. Computed tomographic (CT) scanning has become the gold standard for diagnosing acute pancreatitis. Physical findings creatitis include leukocytosis.&: • pancreas. The pain is variously attributed to stretch. may be lessened by flexed There is no drug treatment for acute pancreatitis. hyperglycemia. There is no appar- dirninish its intensity. agnosis in questionable cases. Other laboratory findings commonly seen with acute pan- lieve the pain and may become protracted. ascites. progressive abdominal distention. Serum lipase elevations are also diagnostic and per- agonizing. although it is actually not needed except for patients with severe disease and suspected complications.' sphincter of Oddi. and elevated liver derness and rigidity. 382 unit viii Alterations in Digestion and Elimination The clinical manifestations of acute pancreatitis vary some. and masses. ing of calcium by fat necrosis in the abdomen. In mild disease backs and draw their knees up toward the body in an attempt to it may only remain elevated for a few days. Drug knee.. and patients may require substantial amounts of opioids. however.J8 Neither amylase nor lipase eleva- Vomiting is a second common feature of acute pancreati. Syn- thetic narcotics such as meperidine (Demerol) have tradi- tionally been used because they do not cause spasm in the I o'"". summarized in Box 42-2. Potassium losses can also be significant in both • Ascites ~j vomitus and pancreatic fluids. height of the enzyme levels. Pain management is the primary consideration.!Qn ~. especially in The clinical manifestations of mild and severe pancreatitis are chronic alcoholics. ~I'~. which may for patients with severe pancreatitis include abdominal ten. Hypocalcemia may develop from the sequester- decreased bowel activity. but it is used cautiously because *NOTE: These signs indicatethe accumulationof bloodinthese areas and these patients are very vulnerable to severe hypoglycemia represent the presence of hemorrhagicpancreatitis. fully monitored. histamine H2-receptor antagonists. excruciating in fulminant to rule out the presence of gallstones. ~~r~~~~N~verity but is usually protracted li and glucagon has not been shown to have any therapeutic ~~:~~~~~:::::~~ Worsened by ingestion of food or fluid .23 Exogenous insulin may be Cullen's sign (bluish discoloration around the umbilicus)* t needed in severe disease. Acute pain in the Diagnostic tests epigastric region is the hallmark feature of the disease. The pain The diagnosis of acute pancreatitis is made initially from is usually steady in nature and may radiate to the back. and serum leveIs need to be Jaundice i maintained. reach leveIs as high as 500 to 900 mg/dl. and patients may curve their within a few hours of the onset of the disease. curved back positioning therapy to reduce pancreatic secretion with somatostatin. ened by the ingestion of food or fluido Vomiting does not re. the measurement of the serum amylase level. ent relationship between the severity of the disease and the ing of the pancreatic capsule. effect.':". abscesses. but it rarely ex. Hypocalcemia develops frequently and is care- Respiratory failure ~. sist for up to 5 to 7 days. and ultrasonography may be used Steady and severe in nature. Replacement of calcium is initiated if the pa- i Grey Turner's sign (bluish discoloration along the flanks)* f tient becomes symptomatic. is now believed to have minimal sphincter effects and is an extremely effective ABDOMINAL FINDINGS • analgesic.18 The levels of urinary amylase and/or chemical burning of the peritoneum by activated en. may also be measured if the patient sustains adequate kidney zymes. It is typ. obstruction of the biliary tree. and respiratory failure. Fluid and electrolyte replacement is criticaI since the loss of I f ". and this is usu- ceeds 39° C. Early Acute Pancreatitis in the diagnostic process abdominal x-rays may be taken to PAIN rule out ulcer perforation. low levels of both albumin and magnesium. Fever is common.-est-a1. tenderness. which complicates di- tis. may radi- ate to the back Medications Worsened by Iying supine. identify cysts. from decreased glycogen and glucagon reserves. Fulminant disease may progress to hypovolemic ally a poor prognostic signo It may occur in conjunction with shock.IIf·· . Rigidity. Urinary output should remain at or above 30 to Oliguria: acute tubular necrosis ~ 50 ml/hr. and with con- trast medium can clearly diagnose hemorrhagic disease. anticholinergic agents. and function tests. guarding Distention Decreased or absent peristalsis. acute tubular necrosis. The severity of the vomiting varies and is typically wors. cases I Located in the epigastric or umbilical region. which rises ically worsened by lying supine. tl intravascular fluid through membrane leakage averages 4 to 6 L and can easily exceed these levels in severe cases. Iça. In more severe forms of the disease the pain may be function.23 Pre- r: ADDITIONAL ISymptoms FEATURES OF FULMINANT of hypovolemic shock DISEASE r !leI vention of hypovolemic shock necessitates aggressive fluid management.

but is Diet probably not necessary unless the patient develops ileus or ex. in Acute Pancreatitis This study was designed to compare the safety. lactic dehydrogenase. LOH.000 domly assigned on admission to receive either total en- LDH >350 IU/L Glucose >180 mg/dl teral nutrition (TEN) via a nasointestinal tube or total par- AST >250 IU/L BUN >45 mg/dl enteral nutrition (TPN) by central or peripheral catheter. Hematocrit decrease >10% LDH >600 IU/L or other prognostic screening tool. The Estimated fluid sequestra. but some procedures may be necessary to con. however. This More aggressive and invasive interventions are available for practice. cost of TPN. Ii obstructing stone can be identified. BUN.2 g/dl sion.11 Efforts are crease in deaths related to pancreatic infection has been ob. parenteral nutrition in mild acute pancreatitis. <60 mm Hg fore normalization of blood values occurred. in theory. The study con- Data Irom Ransom JAC et ai: Surg Gynecol Obstet 143:209. and results mild pancreatitis. the number of days be- Po. Patients were ran- WBC >20. mands. intervention with TPN in this population. Management of Persons with Problems of the Gallbladder and Exocrine Pancreas chap~er42 1383 Treatments surgery typically have fulminant disease and are acutely ill.5 gld and total served.. Once the patient's condition has stabilized. Ransom criteria. and ~.. blood urea nitrogen. The removal of retained gallstones by ERCP reduces protein values above 6.•. NOTE: Presence 01 three or more lactors indicates poor prognosis. and amylase levels return to normal. activity can trol related gallbladder problems. The patient is given nothing by mouth until the abdominal periences persistent vomiting. pseudocyst. (Research Box).IO Oral tluids and feedings can usually prognostic rating scales have been developed to help clinicians be resumed within 3 to 7 days and gradually advanced to a identify patients at greatest risk. and several clinical plications or sequelae. pain has subsided. The modified Glasgow criteria are easier to strictions during recovery except for abstinence from alcoho1. Nasogastric suctioning has frequently been used. rests the pancreas and limits or stops the patients who are at high risk for complications. normal diet once peristalsis is reestablished. aspartate testinal tube appears to be a cost-effective alternative to aminotranslerase.. was more than four times greater tion >6 L than the cost of TEN. and stress-induced glucose lev- eis were significant in the TPN group. or abscesso Necrotic tissue may also be resected. No differences Calcium <8 mg/dl were found in serial pain scores. J Parent Ent Scoring Systems Used Nutr21(1l:14-20. There are no known treatments for pancreatitis.5g/d. but a trend toward a de. APACHE score. The patient is generally given NPO.-~~~ . white blood cell count. serum albu- Base deficit >4 min leveis. Glucose >200 mg/dl Po. BUN increase >5 mg/dl No deaths occurred in either group. No differences were noted between the groups on INITIAL 48 HR ! Calcium <8 mg/dl admission in mean age. Medical The discussion of surgical intervention is included under therapy is direeted at general supportive care for most patients Complications on p. with mild to moderate disease. Age >55 years Age >55 years serum amylase and lipase leveis. . These prognostic scoring systems are pre. <60 mm Hg Nutrition support was initiated within 48 hours of admis- 't Albumin <3.1997. 1386.6 apply clinically. or the incidence of nosocomial infection. and mortality in severe and fulminant disease. 1988. The older system uses the cri. Activity Surgical management Bedrest is maintained during the acute phase of disease Surgery is not a routine part of the management of acute management to decrease the body's overall metabolic de- pancreatitis. There is no clini- teria of Ransom applied at admission and again within the cal proof of the need for a low-fat diet or any other dietary re- first 48 hours.. The course of secretion of enzymes. Clinical (TPN) does not appear to affect outcomes of patients with trials have involved small numbers of patients. but its use significantly decreases morbidity have been somewhat inconsistent.. The early use of total parenteral nutrition creatitis in the attempt to remove toxic substances. cos!. WBC. 1976 and cluded that isocaloric/isonitrogenous TEN via nasoin- Neoptolemos VP et ai: Lancet2:979.• :z=:"" ~~~ effectiveness of two methods of nutrition support for pa- RANSOM GLASGOW tients with mild acute pancreatitis. for patients who are unable to eat for extended periods of time Peritoneallavage has been used in patients with severe pan. Patients requiring research\~il Relerence: McClave SA et ai: Comparison 01 the salety 01 early en- Tvvo Representative Prognostic teral vs. Total enteral or parenteral nutrition may be implemented sented in Table 42-l. made to keep plasma albumin levels above 3. The study involved WITHIN48HR 30 patients who were admitted with mild acute pancre- ADMISSION OF ADMISSION atitis documented by the presence of pain and elevated . thereby maintaining a positive ni- overall morbidity in the select group of patients in whom an trogen balance. AS!.~ ~ •• ~ . Most patients do recover without com- acute pancreatitis is not readily apparent.000 cell/mm3 WBC >15.

g. located in the (e. and continuation of alcohol use will in- crease the risk of recurrent acute pancreatitis and chronic • EXPECTED PATlENT OUTCOMES pancreatitis in the future. • ASSESSMENT 4.. Will assume safe and adequate health practices (e. tachy. Patient and significant others will be able to: Subjective Data a. 2. pain Any number of medical specialists may be consulted to than body requirements manage emergency complications. The nurse needs to be knowledge. decreased skin changes in the regimen. pancreatitis include: b. There Presence of Grey Turner's or Cullen's signs: bluish discol- are no long-term restrictions. epigastric or umbilical region. Will have adequate fluid volume as demonstrated by nor- cohol treatment if possible. dry or sticky mucous membranes in caring for patients with alcohol-induced pancreatitis is that Vital signs: evidence of hypovolemia. trols alcoholism if present as an etiological condition of ens by the ingestion of food or fluid. An enterostomal therapist may be consulted if management draining wounds are left open to heal by secondary intention. or debride maintenance process and therapeutic regimen necrotic tissue.1384 unit viii Alterations in Digestion and Elimination be gradually increased based on the patient's tolerance. Fulminant illness may ne. This is may include but are not limited to: particularly true for patients who develop respiratory com- plications such as adult respiratory distress syndrome Diagnostic Title Possible Etiological Factors (ARDS) or respiratory failure and require intubation and Pain Inflammation of pancreas or peritoneum mechanical ventilation. absence of orthostatic changes. relieve obstruction. sits with knees mented by boluses as needed for breakthrough pain. The severe nature of acute pancreatitis may pain (does not display distressed appearance. and either morphine or Objective data to be collected to assess the patient with acute meperidine (Demerol) may be used. Nursing diagnoses for the person with acute pancreatitis cessitate critical care monitoring and consultation. vomiting does not acute pancreatitis). An attitude occasionally encountered turgor. mal blood pressure. usually severe and protracted. Nutrition. It movement. relieve pain History of gallbladder disease. tachycardia. is important to use this opportunity to refer the person for al.g. Expected patient outcomes for the person with acute pancre- able about resources available in the local community for sup. Patient- pulled toward abdomen controlled analgesia should be used if feasible to allow for suc- Fever. generally <39 C 0 cessful pain management. The nurse anxiety must serve as the patient's advocate in the system. moist mucous membranes. or limited activity). the patient is somehow "getting what he or she deserves. Will gradually resume a normal oral diet without discom- fort and regains lost weight . atitis may include but are not limited to: porting individuals who want to become and remain absti. limited body serve as a stimulus for lifestyle change in some individuals. Explain plans for follow-up care. distention. HeaIth maintenance. c. data. long-term high alcohol intake . con- Nausea and vomiting. normal skin turgor. and tenderness frequently assess the patient's levei of pain and response to in- Diminished or absent bowel sounds terventions. The nutrition support team will be Fluid volume deficit Vomiting. restlessness. oration on flanks and/or around umbilicus Jaundice Referrals Patients with acute pancreatitis are severely ill and may • NURSING DIAGNOSES require the expertise of a variety of specialists during the Nursing diagnoses are determined from analysis of patient treatment and recovery periods. and pecially on repeat admission for recurrent disease. aItered: less Nausea and vomiting. The surgeon is often Risk for impaired home Lack of knowledge about disease needed to drain abscesses. worsens when patient is supine 5. fluid shifts in abdomen involved if TPN is initiated. and adequate urine output. I. UnhealthY lifestyle patterns.INTERVENTIONS Controlling Pain Objective Data Control of pain is a major priority. Describe the disease and the purpose of various inter- Subjective data to be collected to assess the patient with acute ventions. wors.14 The nurse will regularly and Abdominal rigidity. in- In many patients alcohol abuse is the etiological stimulus aItered cluding aIcoholism of acute pancreatitis. NURSING MANAGEMENT 3. normal to low blood pressure. alcoholism or biliary disease) and pancreatitis. The physician will be consulted for needed Signs of dehydration: falling urine output. Critically ill patients pancreatitis include: may receive a continuous infusion of N narcotics supple- General affect: patient looks distressed.. document- ." es- pnea. may radiate to back. guarding. Explain the relationship between the etiological facto r Pain: steady and severe in nature and quality. States that pain is controlled and does not appear to be in nent from alcohol.

Monitoring parameters and frequency of patient to follow through on recommended treatrnent. vital signs. oral fluids and food are restarted. it may be treated with insulin. others need basic information about the disease. b. Appropriately describes the disease. Appropriately describes and selects well-balanced diet. Maintains NPO status as appropriate. the diagnos- knee-chest position with their knees drawn up to the ab. Management of Persons with Problems of the Gallbladder and Exocrine Pancreas chapter42 1385 ing the severity of the pain and ensuring that an effective plan Patient/Family Education is in place to manage it. the beginning of hospitalization. treatrnent. Returns to normal weight. The patient is given clear liquids and then slowly advanced to. or blood will be given as • EVALUATION necessary. Because of the pain and the dis- domen. itored for hyperglycemia. Support and continuity of care also need to be be inserted to keep the stomach decompressed if vomiting is provided to help decrease anxiety. 2. Monitoring includes intake formation on coping with alcoholism. When the acute symp.it will routine laboratoryvalues with particular emphasis on potassium be important to stress the importance of treatrnent for gall- and calcium levels. massage. This care will not be instituted until the pa- AB soon as the patient is admitted. the nurse should institute tient's condition is stabilized. electrolytes. the patient leaves the hospital. and all If the patient's pancreatitis is related to biliary diseasé. in the elderly patient. shows intake equal to output. be performed four times a day.The patient also is mon. disease in the development of pancreatitis and encourage the sion and shock. narcotic administration for pain control. Fluids. the patient reluctant to undergo any further medical or surgical An indwelling Foley catheter may be necessary. or a side-Iying. The nurse will reinforce the etiological role of biliary creased renal function can occur in association with hypoten. and the treatment. but it must be introduced before monitoring related to fluid and electrolytestatus. Makes commitment to treatment for alcoholism. The severity of the disease is difficult to . the nurse must work with the patient on Maintaining Fluid and Electrolyte Balance the problems. and output. States no pain. Education will be directed severe. vomiting. Promoting Adequate Nutrition 4a. Al. ular concern in the early days of the disease. and conducive to restoThese measures are used in addition to. comfortable. iary disease. Follow-up care ing distraction. or pain by discharge. The environ. TPN may be used during the criticaI phase of the c. Successful achievement of patient outcomes for administering the fluids and for monitoring the patient's for the patient with acute pancreatitis is indicated by: response. cardiac output. Appropriately describes the relationship between etiolog- to decrease discomfort from NPO status and from the naso. and biliary disease-related pancreatitis is most likely to occur charge is the avoidance of alcohol. colloids. must be explained in detail. ment should also be kept quiet. If severe hyperglycemia occurs. Good oral hygiene will be necessary b. la.Physicalassessment will include assessing for stones. diet. See Chapter 14 for further in- and renal status. watches carefully for the early signs that could indicate the de. symptoms should be reported immediately. At Some patients find that the pain is decreased if they as. daily weights. Consumes a well-balanced diet without nausea. the patient and significant sume a sitting position with the trunk flexed. Teaching the patient and significant others will be ongoing. gastric tube. To evaluate the effectiveness of nursing interventions. b. nasogastric tube in place. monitoring will depend on the stability of the patient's condi- tion.The episode of pancreatitis is frightening and could make signsofhypokalernia and hypocalcernia (see Chapter 15). and breathe shallowly. grimace. and checks of blood glucose should 3a. It is a critical need. or back rub. Therefore explanations and instruc- will be given nothing by mouth to "rest" the pancreas and de. and the nurse b. tic tests. Frequent small GERONTOLOGICAL CONSIDERATIONS mealsare usually better tolerated in the early refeeding period. the patient and family may be experienc- though the research is currently inconclusive most patients ing tremendous anxiety. and not in place Health Promotion/Prevention of. Has hemodynamic measures within normal limits and velopment of shock (see Chapter 17). Biliary disease becomes increasingly common as people age. The patient must know that any recurrence of signs and pharmacological pain relief strategies with the patient. imagery. abdominal girth. and planned in- The patient will be given nothing by mouth and often has a terventions. c. since de. the disease process. Tolerance for oral feedings is carefully as- sessedas is the possibility of the return of pain. toward preventing future attacks and maintaining a nutritious The nurse will also explore the use of a variety of non. ical factors and the disease. The nurse is responsible tient outcomes. com- Aggressive fluid replacement will necessitate establishing pare patient behaviors with those stated in the expected pa- and maintaining large bore IV access. tions should be brief and as simple as possible and may need crease the autodigestive processoA nasogastric (NG) tube will to be repeated. tests. includ. Does not splint. Epidural analgesia can be used if pain is persistent tress acute pancreatitis causes and because of the severity of and not relieved by routine narcotic administration. 5a. ward a regular diet. Correctly identifies planned follow-up treatrnent for bil- toms decrease (3 to 5 days). The only diet restriction that needs to be followed after dis. The development of hypovolemic shock is of partic. If unhealthy lifestyle patterns such as alcoholism are a cause of acute pancreatitis. illness for patients with severe disease.

. but elderly patients with acute pancreatitis may be. pancreatic ascites did not develop. and most deaths associated with the dis- The same is true for the development of hypovolemia and ease occur in that group of patients. suc. and both shock and sepsis •• af Acute Pancreatitis place extraordinary metabolic demands on the respiratory ~~~. A pulmonary artery catheter may be inserted to assess perfusion adequacy._~:. system that can progress into full-blown ARDS in some pa. Other interventions will be di. Respiratory failure accounts for a ondary infections.t=. The systemic complications tend to occur may overwhelm the elderly patient's ability to adapt and within the first week and have largely been discussed within respondo the context of the fulminant disease processo These include complications such as hypovolemic shock. if the patient agrees. and intervention is not always war- itoring and aggressive fluid support. spontaneously over time. These patients will be managed in a criticaI care unit. nated intravascular coagulation (OIC) from unknown In addition to the concems addressed above.s~~. pneumonia. pseudocysts can also become life threatening may also need cardiac support with drugs such as dopa. adult respira- through a peritoneal catheter.. and elderly patients are less About 25% of patients who have acute pancreatitis will de- able to withstand the stress imposed on the body by sepsis. pancreatic abscesses. hypocalcemia. if they obstruct neighboring structures. dissemi- disproportionate number of pancreatitis-related deaths. however. However. renal failure. The nurse's role is to be certain that the patient has atitis.. Major Complicatians limits diaphragmatic excursion. that Elders are also more likely to develop complications related the decision to continue drinking is a matter of personal to their disease-enforced immobility as well as to the pancre. HEMATOLOGICAL tioning as needed._:a.. These factors strain the cardiovascular system and local or systemic. Hypercoagulability increases the risk of pulmonary albuminemia embolism. choice. SPECIAL ENVIRONMENTS FOR CARE and ARDS.1386 unit viii Alterations in Digestion and Elimination predict. only 5% to 10% of all patients. Assess. Pancreatic pseudocysts. Complications may be fluid shifts. Normal activities are gradually resumed as strength and activity tolerance increase. and aggressive chest physiotherapy. It is important to recognize. GASTROINTESTINAL Home Care Management GI bleeding Most patients with acute pancreatitis recover spontaneously PANCREATIC and can be discharged from the hospital within 1 to 2 weeks. Prompt intubation and mechanical ventilation will be Hypotension/shock from hypovolemia or hypo- crucial.f'". rupture or hemor- mine. Respiratory complications are of particular concem. all of the information that he or she needs to make an in- and the elderly patient needs frequent respiratory assessment formed decision about the future.. RENAL Patients with alcoholism present a unique challenge as Oliguria and acute tubular necrosis even the pain and anxiety of acute pancreatitis may not be suf.. the disease. hyperlipidemia will discuss the importance of abstinence with the patient and . This process occurs in vention or identification of complications. anemia from blood loss. make referrals to community programs for alcohol treatment come critically ill faster because of comorbid problems.. Leukocytosis from generalized inflammation or sec- ment is conducted hourly. sepsis. Pancreatic fluid or exudate forms in up to 50% of patients The nurse's major roles are collaborative with the physician with acute pancreatitis.. tory distress syndrome (AROS) rected at specific complications as they arise.. Infection is a common complication of pancreatitis (see COMPLlCATIONS discussion under Complications). A positive outcome cannot and aggressive pulmonary hygiene during the acute stage of be guaranteed... CARDIOVASCULAR tients.. Left ventricular dysfunction is a com- mon problem.. The major complications of acute pancreatitis are Criticai Care Management summarized in Box 42-3. METABOLIC ficient motivation for them to abstain from alcohol. of fluid enclosed in a fibrous capsule. Management includes supplemental oxygen.6 Pseudocysts are rounded collections and involve ongoing monitoring of all systems and the pre. Critically ill patients ranted.~=:l. The airway is compromised in several ways. Although most patients with pancreatitis recover without any residual dysfunction.. pleural effusion. Severe pain . The nurse Hyperglycemia. a minority experience life-threatening Pseudocysts disease. pancreatic necrosis or phleg- Patient needs for home care will be minimal if complications mon.:" . velop complications.6 Many pseudocysts resolve Routine interventions will include hemodynamic mon. the critically causes ill patient with pancreatitis will receive TPN to support a pós- RESPlRATORY itive nitrogen balance and may undergo peritoneal lavage Atelectasis..

which can then be aspirated by CT-guided needle struction occurs secondarily. Management of Persons with Problems of the Gallbladder and Exocrine Pancreas chapter42 1387 rhage. affecting both sensory and motor functions. Other potential causes of chronic pancre- atitis include neoplasms. Inflammatory tissue.1 It is pos- drink. or become infected. Symptoms include diarrhea. Secretions are possible and then place multiple large-bore sump drains in more viscous and tend to form calcium-containing stones. The initial diagnosis of infection can be struction of the exocrine parenchyma and replacement with complicated by the fact that acute pancreatitis itself manifests fibrous tissue. or throughout the total abdomen. ingly severe the islets of Langerhans are also involved and quires percutaneous drainage or surgical debridement. rarely. Theo- to already have asymptomatic chronic disease when they ex. Intervention is again not indicated pancreatitis in which pancreatic function essentially returns unless bleeding or infection develops. tempts to prevent the development of infection with the rou. usually in areas of fat necrosis. to have such detrirnental effects. Gram stain and culture can then identify the spe. chronic pancreatitis a separate disorder from recurrent acute which is called a phlegmon. tulae can complicate the healing processo Nausea. the operative areas to remove infected material. constant and is not relieved by food ingestion or antacids. which is . The development of fis. tis. As with pseudocysts to normal when the inflammation subsides. In addition there is evidence proach had been to excise as much necrotic material as of small protein plugs in the acinar ductules. the likelihood of recurrence is extremely high. tency.2 Continuous Trypsinogen and other proteases are activated by poorly un- saline infusion and suction were needed to maintain tube pa. Chronic sible that much of the pain is eventually related to this nerve pancreatitis is discussed below. some genetic defect must also exist that allows alcohol Percutaneous drainage is used most effectively with in. Many surgeons now recommend an open method in The patient with chronic pancreatitis may initially have which the resected are as are packed. and the dressings are signs and symptoms identical to those described for the pa- changed under anesthesia every 2 to 3 days until granulation tient with acute pancreatitis. The factors that influence the aspiration. The pathological nature of fected pseudocysts because there is minimal particulate mat. As the process becomes increas- antibiotics are initiated immediately. although the pain is not different in nature or severity from that which accompanies acute pancreatitis. tis remains obscure. occurring in acute pancreatitis. Chronic pancreatitis is present when recurrent bouts of in.2 In. If the patient continues to nerves. Ductal ob- af necrosis. and occur throughout the pancreas or be limited to selected the patient's clinical condition deteriorates. areas. retically the dense fibrosis can entrap and alter the pancreatic perience their first acute episode. derstood mechanisms. The traditional surgical ap.'·23 Chronic pan- the pWegmon may be drained. The pain occurs in the right or left upper quadrant. typically exceeds 39° C. Pancrea~icInfec~ion inflammatory problems such as inflammatory bowel dis- As treatment for systemic complications has improved. but they are usually secondary to the pain. It is severe and placed once granulation is underway.' It is CHRONIC PANCREATITIS frequently worsened by eating and needs narcotic administra- Etiology/Epídemiology tion for control. lems. or resected creatitis occurs almost exclusively in alcaholics and is more as needed. Calcium salts may be deposited in both the ducts and CT scanning allows for the accurate identification of areas the parenchyma. pancreatitis. and abdominal distention may be present. vomiting. Pathophysiology fection usually develops in the are as of necrosis created by The basic pathological change of chronic pancreatitis is de- fulminant disease. with pain being the major man- is well underway. destroyed. Chronic Pancreatitís In the alcoholic patient it is very difficult to decide where Patients with alcohol-induced acute pancreatitis are believed acute pancreatitis leaves off and chronic disease begins. At. Biliary tract disease creatic infection has become the most frequent cause of seri. grees of duct dilatation. tissue is destroyed. solubility of calcium in the calcium-rich pancreatic secre- cific organisms responsible for the infection. Scarring and fibrotic changes may Infection-related fever. A "wait and see" policy is generally creatic tissue with gradual fibrous replacement of the normal followed. common in men. The abdomen is left open and eventually ifestation. This process is associated with varying de- with the common symptoms of inflammation and infection. ease and primary sclerosing cholangitis. however. doses over an absorbable mesh barrier. pan. Broad-spectrum tions are not well identified. and the cysts are monitored regularly. entrapment. surgically debrided.21·23The progressive degeneration of the gland makes exudate from the pancreas may form into an inflamed mass. the alcohol-induced injury is believed to be similar to that ter present that can clog the tubes. structural problems. remains the primary causative facto r in acute recurrent ous morbidity and mortality associated with acute pancreati. The role of alcohol in both acute and chronic pancreati- tine use of antibiotics have not proven to be effective. Pancreatic insufficiency begins once 80% of the pancreatic flammation lead to progressive injury and scarring of pan. Alcohol appears to act as a direct toxin. and. although irnipenem (Primaxin) is able to effectively penetrate but since only a minority of heavy drinkers develop prob- the capsule of the pancreas and shows promise. but definitive therapy re. A feeding tube is in the back. Infection typically appears 8 to 20 days after the onset of pancreatitis and has a 100% mortality rate if untreated.

These can be mixed directly with food. and calculi. Ex.1388 unit viii Alterations in Digestion and Elimination often steatorrhea. monly associated with long-term alcohol use makes adher- tient's 'nutritional state is being evaluated in several research ence to a high-protein. with pain management during previous hospitalizations for but an association has been noted with cigarette smoking and . Patients can usually adapt right to make fundamental decisions about his or her own to the malabsorption and steatorrhea. CANCER OF THE PANCREAS The nurse serves as the patient's advocate in the search Etiology/Epidemiology for eomfort. Concerns about drug dependenee must not be Cancer of the panereas may arise from any of the elements of allowed to prevent the patient from receiving adequate and the pancreas. The recommended diet is high in protein and carbohy. insulin. Sympathectomy is occasionally performed to re- lease the entrapped nerves. The patient is instructed to monitor the being. Patient/falTJi/y education toms of deficiency. Health care providers can easily be. Powders a low-fat diet and supplemental pancreatic enzymes. and is not amenable to surgical correction. which are frequently accom. The involvement of a pain management team is desirable if nerability to hypoglycemia and a smaller need for insulin. dynamics are supportive. are adenocarcinomas. The nurse provides the patient with written material that tion is frequently used to attempt to relieve the chronie ab. The role of alcohol in the etiology and progression of A history of acute pancreatitis is the best diagnostic con. but the persistent pain care. have a better prognosis than adenoeareinomas. 1389. and use pancreatic enzyme replacement effectively to control Flare-ups of chronic pancreatitis are managed just like diarrhea and maintain a stable weight. chronic pancreatitis is unequivocal. Unique meta. and both fasting and postprandial use. The nurse consults with a substance abuse specialist to hyperglycemia are usually present. outlines the symptoms of complications and encourages the dominal pain. and even abstinence to understand and accept that ultimately it is the patient's is eventually no guarantee of relief. Bowel rest is maintained. bolic derangements in glucose metabolism create a strong vul. and marked weight loss. The patient also needs to learn how to modify the diet panied by poor outcomes and multiple complications. sary to make informed decisions about his or her present and brosis. The nurse teaches the patient to take the to managing the acute pain. dergo risky surgical procedures. Malabsorption sion of pain management. Patients who continue to Family members and health care workers need to be helped drink alcohol will continue to have pain. such services are available. although most involve the ductal epithelium and necessary analgesia. also arise from the islet cells but these are rare. and attention is paid ications is critica!. The etiology is unknown. Diabetes is com. This attitude can seriously eompromise Pancreatic cancer usually occurs in persons older than the patient's care. 50 years of age. atrophy. leads to clinicai deficiency in vitamins E and B12 and other fat-soluble vitamins.1S Tumors of the ing to stop drinking and can begin to consider the pain of islet cells usually retain some endocrine functions and tend to chronic pancreatitis as appropriate retribution for the pa. Ongoing care involves the use of eapsules 1 to 2 hours before. Surgical interven. The involvement of the family is encouraged if the Effective management of abdominal pain is the greatest chal. Information coneerning community resources for al- cohol treatment should be current and accurate and offered to Collaborative Care Management the patient. duct dilatation. body's response to the supplements and consistently track drates and may provide as much as 3000 to 6000 calories/day. In some instances the patient has had negative experiences It is much more common in men. Patients who continue to drink alcohol will always be Chronic pancreatitis affects the small ducts of the pancreas just one step away from their next flare-up or complication. tient's care and ensures that the patient has ali the data neces- CT scanning is the basis of diagnosis and can demonstrate fi. tient's addiction. Patients are informed that extraets will increase the patient's body weight and improve these products frequently produce a bad taste and may alter absorption. future. A tensive pancreatic resection or pancreatectomy may be Nursing Care Plan for the patient with chronic pancreatitis performed in patients who are unable to refrain from drink. Both benign and malignant tumors can come exasperated with patients who are unable or unwill. exacerbations and thus believes that analgesics are not being mon and mayprecede other clinicai symptoms. even when these decisions do not appear to be in the pa- may lead to drug dependence and motivate the patient to un. inereasing the patient's general sense of well. and yet many alcoholics nection to chronic disease. high-calorie diet difficult. ing alcoho!. but patients rarely develop overt symp. during. lenge with chronic pancreatitis. but there are no proven surgical solutions. but it can develop at any point in the lifespan. Fat-soluble vitamin replacement may also be indicated. The use of trials. the taste of foods. The anorexia and poor eating habits com- The use of medium-chain triglycerides to improve the pa. or after meals. See Chapter 12 for further discus- Oral hypoglycemic agents are not effective. vitamin supplements is encouraged if recommended by the and the management of diabetes often requires the use of physician. tient's own best interests. given because the health team does not care about him or her. patient to adhere to the plan for continued follow up. Timing of the med- acute disease. Stool examination can develop a consistent and appropriate approach for the pa- quantify the severity of the steatorrhea and malabsorption. weight changes. Amylase and lipase levels will ris e find themselves unable or unwilling to abstain from alcohol during recurrent attacks. is found on p.

and foul-smelling stools that have been increasing cose> 160 in frequency and severity over the last few weeks. Synthetic narcotics are effective needed. A regular time schedule of drug gesics on a regular rather than use allows for a steady blood PRN basis. K+ of 3. daily weight. He is admitted now with another said the pain would stop if I stopped drinking so much and look II flare-up of the disease. shallow. relaxation. cially before and after administra. The pain starts so quickly when I drink that [ j 12-year history of acknowledged alcoholism. N saline with 20 mEq of KCI man who appears older than his stated age. and glucose of 162 mg/dl. 1. in dose or drug as needed. Recording on a flow sheet allows sheet. trol of the pain experience. Collaborate with Mr. b. He has had nothing to eat or drink for more than ing persists past 4 PM 12 hours.2 g. and abdominal girth epigastric region and radiates to the back. and respirations are 22 and cipitated his descent into alcohol dependency. 1. flexed. Acute pain can be immobilizing. delirium tremens (DTs) • A history of decreased alcohol use over the last 3 months.9 million. Patients with chronic pancreatitis reality ofthe patient's pain and are frequently labeled "drug its severity. 50ft. and be willing to experiment with new strategies. tion of analgesics. This position is theorized to re- Fowler's position with his knees duce tension on the abdomen. seekers" by staff. at 125 rnlIhr ence of: • NPO • Acute abdominal pain that is generally localized in the mid. cal! house officer if glu- Large. Document pain leveis on flow a. do is changing that. Assess pain leveis frequently. b. He's killing himself and nothing I say or 10. watching him die. validate the nature and severity of macological methods. 3. e1ectrolyte imbalance. He reports the pres. It hurts toa much. • • • Person with Chronic Pancreatitis I I DATA Mr. c. • Blood pressure is 94/60.'s admission assessment shows a thin. Validate your acceptance ofthe b. the patient's pain experience. • Demeroll00 mg IM q 3 hr PRN for pain • Steady and protracted vomiting that began late yesterday af. I don't think I can stay around any longer serum calcium of 8. His longest period of so. T.8° F. and guided patient must have an open mind imagery. a. Maybe I should just drink myself to death and get it Mr. a. analgesics and do not cause spasm in the sphincter of Oddi. narcotic order. Position him in a mid to high a. He rates the pain as once daily an 8 on a 10-point scale in severity. red blood cell count of 2. stand why this should happen now.2 mg/dl. a. He has lost • Monitor c10selyfor hypovolemic shock. Other data on admission include: briety has been about 6 months. Continued . espe. methods of pain control.0 mg/dl." undergone inpatient alcohol treatment. has made several efforts to stop drinking and has even over with. poorly nourished • IV of 1000 ml of 5% dextrose in li. Collaborate with Morphine may be substituted physician to make adjustments for meperidine. levei to be established." [nitial care orders include: Mr. for a pattem of pain to be estab- lished and the effectiveness of pain control to be evaluated. Ali of these can be effective strategies such as distraction. I don't under- first attack of acute pancreatitis 4 years ago and chronic pancre. Mr. Some life stressor has always pre. Evaluate effectiveness of the c. pulse is 92. at me now. Frequent assessment is essential to with pharmacological and nonphar. • Accucheck 4 times daily per protocol. What's the use? The doctor I atitis has since been diagnosed. Encourage patient to use anal. Explore his experience with b. Temperature is 99. tion if needed NURSING DIAGNOSIS Acute pain related to distention of pancreatic capsule and activation of pancreatic enzymes States pain is effectively controlled 1. but the massage. 2. T to determine 3. 1. Administer meperidine q3h as 2. 12 pounds. • Insert NG tube and attach to low intermittent suction if vomit- ternoon. is a 52-year-old self-employed accountant with a ing much less. nies him to the hospital but is quick to say"I don't think that I can • Bloodwork shows the following abnormalities: hemoglobin of take much more of this. • Monitor intake and output. He experienced his have really been steadily decreasing my intake. His wife accompa. a. Nonpharmacological methods the nonpharmacological methods allow the patient a degree of con- that help to reduce his pain. T • Call substance abuse resource counselor for DT protocol initia- says "I know no one will believe me but I've really been drink.

Continueo . Assess skin turgor and status of 30 to 50 ml/hr is essential to pre- mucous membranes each shift. believed to bind with free fats and tips or around mouth. Fluid replacement is based on esti- b. Fluid and gas accumulation in GI e. Evaluate composition and volume of 7. large-volume. Because of the risk of labile hypoglycemia. 4. to oral feeding. NPO status is theorized to reduce or TPN to maintain stable body until patient's condition stabilizes. Once pain and enzyme leveis are dominai pain is controlled and amy. This feeding pattem minimizes patient's tolerance. body's metabolic rate. Weigh daily. and the severity of malabsorption needs to be es- tablished.8 g/dl. Maintain NPO status and bed rest 1. Offer small. keeps albumin leveis above zymes. symptoms. Adequate enzyme replace- ment will restore the stool to near normal. and malabsorption caused by loss of function of pancreatic enzymes Receives sufficient nutrients by mouth 1. assess patient distention and malabsorption response. each shift. dominal distention. 2. to fluid replacement. intake and output are bal. Monitor for hypokalemia and 3. greasy. 6. digestion of fats.. stable there is no contraindication lase/lipase leveis stabilize. rapid catabolism of the disease must be counteracted by TPN to prevent life-threatening complications. calcium is numbness and tingling in finger. are often malnourished before the attack from alcoholism and malab- sorption. foul-smelling zymes to achieve normal elimination. Reinitiate oral feedings once ab. NURSING DIAGNOSIS Altered nutrition: less than body requirements related to vomiting. Maintain accurate intake and 4 to 14 L of fluid into the abdomen. 5. May lose anced. hyperglycemia. vere hyperglycemia. Adjust dose of pancreatic en. weight is stable. Monitor cardiovascular response necrosis. initiate TPN if NPO status needs to 4. 1. Restrict fat in diet if steatorrhea a. 3. Assess fluid and electrolyte status 1. Assess current nutritional and elimi. Malabsorption manifests itself as stools. Large amounts of potassium are hypocalcemia: lost through vomiting and in the muscle weakness. NPO status. 2. A urine output of c. If pain is not controlled promptly the be protracted. ongoing data about nutritional status. the secretion of pancreatic en- weight. Monitor blood glucose 4 times daily. vent the onset of acute tubular d. and produces normal stools. 3. Measure abdominal girth daily or tract can result in significant ab- as ordered. positive can drop to leveis that increase Chvostek's and Trousseau's sign neural excitability. mates of losses. shock and dehydration. stools. 7. Malabsorption primarily affects persists. output. Patients with chronic pancreatitis nation status. NPO status. Administer sliding-scale insulin islets of Langerhans produces se- per protocol. frequent feedings to the 6. cramping pancreatic secretions. These parameters provide the best protein and albumin leveis. a. in- sulin is not given unless glucose levei continues to rise. 2. Bed rest decreases the 3. a. Monitor daily weight and serum 3. and increased capillary permeability Maintains balance of fluids and elec. Patient is at risk for hypovolemic trolytes. 2. Destruction of the beta cells and a. 5. 1390 unit viii Alterations in Digestion and Elimination Person with Chronic Pancreatitis-cont'd NURSING DIAGNOSIS Risk for f1uid volume deficit related to vomiting.

. was shown to be a clear risk facto r. porto Refer as appropriate. tumor is usually deeply encased in normal tissue and is poor1y Incidences of familial c1ustering of cases point to a hereditary demarcated. the sixty-five percent reported Cajun ancestry. Metastasis has almost has been suggested but remains unproven. They reported a to. Management of Persons with Problems of the Gallbladder and Exocrine Pancreas chapter42 1391 . tachy- cardia.000 nationwide). diaphoresis 6.000 nationwide). Withdrawal substance abuse specialist if carries a high mortality in acutely needed. Person wíth Chroníc Pancreatítís-cont'd NURSING DIAGNOSIS Risk for ineffective management of therapeutic regimen related to inability to abstain from alcohol and inadequate knowledge of management of malabsorption and hyperglycemia •• 01 • Verbalizes understandíng of disease 1. Insulin may be needed to control planned management of diabetes. Teach patient correct use of pancre. Assess knowledge of community stated the end of her tolerance for resources for treatment and sup. and the . 6. especia1ly in women. Direct ex- Pancreatic cancers usually deve10p in the head of the gland tension of the lesion may cause its spread to the posterior and vary dramatically in size at the time of diagnosis. Consult with current levei of use.OberletinerMG: Familialpancreatic pancreatic cancer. African Ameri- diana region of Louisiana. Assess for symptoms of DTs during 3. Although flawed by sampling difficulties. well-informed patient. Malabsorption is permanent. mitment to abstain from alcohol. 1996.000 versus 17 per and used a questionnaire to explore cancer incidence and risk 100. Sampling was difficult as pa. The wall of the stomach. Patient has stated his attempts to alcohol.íJ. 1. Thirty-eight patients or family surrogates were en. cantly increased for whites (18 per 100. justments can be safely made by a justment. vented. A link with chronic pancreatitis tended by the presence of the tumor. Assess patient's current under.PayneRL. standing of the disease process and planning and intervention. the future. the colon. the presence of long-standing diabetes. Heavy prolonged cigarette smoking mented during the year of study. which has been true in tients rapidly beca me extremely ill or died. always occurred before the tumor produces its first symp- toms beca use there is no capsule surrounding the pancreas Pathophysiology to prevent the growth and spread of the tumor.000 versus 10 per rolled from among the 140 possible cancer patients docu. Of the sample ali samples. 5. research ~ Reference:PriceTF. • Hypoglycemia: anxiety. only 2% of ali new cancer diagnoses. The incidence rate was also signifi- lactors. Makes commitment to abstain from 2. adequately replaced. the diabetes of chronic pancreati- a. abdominal glycemic but must know how to cramping recognize ketoacidosis. 3. Wife has a. 2. Patients with chronic pancreatitis ment to changing his lifestyle and often have given up hope on them- gaining control of his disease and selves and their ability to inlluence his life. above national norms where pancreatic cancer accounts for This study explored a possible familial predisposition to pan. Patient may not be truthful about first 48 to 72 hours. This establishes a baseline for process. Dosage ad- tency to judge need for dosage ad. The sample incidence creatic cancer among a Cajun heritage population in the Aca. 4. The common duct is often obstructed and dis- component (Research Box). decrease alcohol use. role of alcohol. the role of alcohol in its recurrence. Teach symptoms to report: tis. Patient will remain hyper- tion. Encourage patient to make commit. Assess patient's interest and com. 100. but hypoglycemia must be pre- Hyperglycemia: frequent urina. rate was comparable to that of lung cancer. lethargy. The study was descriptive in nature cans had the highest incidence (32 per 100. and pharma. 4.Cancer Nurs 19(4):275-282. ill patients and necessitates spe- cialty asisstance . the duodenal wall. ent deficiencies if enzymes are not Monitor weight and stool consis. Teach patient about the nature and 5. thirst. cological management of symptoms. study does appear to confirm the presence of a significant tal of 366 first-degree reiatives of whom 44 had also developed familial risk for pancreatic cancer in this unique population. and atic enzymes: patient will develop serious nutri- • Take with each meal and snack. This represented an incidence rate lar cancer in SouthLouisiana. his continued use 01 alcohol.

internally or inserted for externaI drainage. Weight loss fre. extend life e>""Pectancyto nearly 1 year. A histological diagnosis is important in plan. Provide support for patient and family and initiate dis- figo 42-6 Pancreatoduodenectomy (Whipple's proce. Instruetion is alsl Collaborative Care Management provided about expeeted side effeets and their managemen1 The diagnosis of pancreatic eancer is often first ma de based on Other general measures are those provided to any patient witl the pattem of symptoms and then is confirmed through ÍDvasive eaneer (see Chapter 11). atie eaneeI. Monitor patient's weight and the development of steatorrhea. Advance as tolerated. lines for Care Box. and hemody- namic parameters. intake and output. but combination protocols used in research trials appear t Pain is the earliest and most eommon symptom of panere. It occurs or is wors. oxygen saturation. Assess for signs of dumping syndrome (see Chapter 40). Neither radiotherapy nor ehemotherapy Check vital signs. Keep skin clear of drainage.1392 unit viii Alterations in Digestion and Elimination eommon bile dueto Vital blood vessels in the are a are also fre. aIthough surgery has not been proven to improve survival. Less than 2% of patients survive 2 years. Maintain nutritional support with TPN. tomy (Figure 42-6). Gollblodder Stomoch Initiate oral feedings with clear Iiquids. Diabetes may aIso tion. Maintain urine output at 30 to 50 ml/hr. Perform blood gas. Guided needJe biopsy may be performed at undergoing pancreatie surgery is summarized in the Guide the same time. Monitor dressings and drainage tubes. Se alert to signs of bleeding or shock. Monitor Cystic duct every hour. jejunostomy to relieve biliary obstruction. Anorexia The nurse serves as the patient's advoeate in the health car is also common. considered as an altemative to surgery. aIone has had any positive effeets on the course of the diseaSI quently involved. Administer TPN if ordered. charge planning. The Pain management is an ongoing chaIlenge with panereati pain is relentlessly progressive in nature. and surgi cal bypass is frequently attempted. vitamin K and other c10tting factors may be ad- ment of stent tubes to support biliary drainage is increasingly ministered. Initiate pulmonary hygiene every hour with deep breathing. Stents may be placed Assess nutritional status. Monitor blood glucose and administer insulin as or- dered. The pain is usually deseribed as epigastric in loca- tion and steady and severe in character. dure) vvith anastomosis. and use of incentive spirometry. coughing as needed. and routine blood studies. . ning eare. The nurse provides careful teaching about the use of nar develop. Patient/farnily education ened by lying down and bears no relationship to meals. Endoseopic place. cotic anaIgesics and the inevitable development of toleranc and physicaI dependence (see Chapter 12). guide'ines ~or carE The treatment is generally surgical. Nursing care of the patien CT scanning. ]aundice and pruritis will typically develop system to establish an effective pain management protoec when bile duet obstruetion oecurs. Procedures include Provi de thorough teaching about planned surgical pro- cedure and expected postoperative care. Establish effective pain management regimen. Administer pancreatic enzyme replacement as Jejunum / ordered. Obstruction is a common The Person Undergoing Pancreatic Surgery Preoperative Care problem with large tumors involving the pancreatie head. Criticai care place- the more aggressive Whipple proeedure or total pancreatec- ment is usualiy necessary. Postoperative Care Surgeons who are attempting curative procedures may use Monitor vital parameters every hour. and continuously adapt it to changes in the patient's condi rhea develop fairly late in the disease. gastrojejunostomy to bypass the duodenurn and choledocho- Monitor prothrombin time and other clotting studies.9 Cancer of the panereas is usually fatal within 6 months re- gardJess of treatment. cancer and is often the primary determinant of quality of lift quently accompanies the pain and can be dramatic. Diarrhea and/or steator.

pain. Gauwitz DF: Endoscopic cholecystectomy: The patient friendly ai- 11 Cholelithiasis and cholecysitis are common health prob- ternative. Ondrusek RS: Cholecystectomy: an update. Domingues-Munoz JE. Oberleitner MG: Familial pancreatic cancer in NPO status. Dest V: When the diagnosis is pancreatic cancer. Am Fam ity. Brozenec S. 19. scopic Cholecystectomy. 16. problems. hemorrhagic forms is high.1992. Blue has a T-tube present after an abdominal patient continues to drink alcohol. Hartranft TH: New trends in the treatment of calculus dis- • Care in acute pancreatitis focuses on pain management. • Chronic pancreatitis results in pain. In rare instances a pancreatoduodenectomy nurse be alert for? Why? How should he or she may be performed. Nursing 20(12):58-59. Am J Nurs 91(9):38-48. New York. Crit Care Nurs Clin North Am pain. Ambrose MS. • Chronic pancreatitis is progressive and usually results from 21. 1993. 5(1):185-201. 2.1992. 1996. 1997. Hill. CHOlE L1THIASIS/CHOlECYSTITIS/ 6. 1991. Dreher HM: Pancreatitis-managing a flareup. RN 56(1):28-31. Kohn CL. 1995. 1995. nausea. 1993. Gastroenterologist 4:248-253. Postgrad Med 71(2):67-70. alcoholism. with pancreatobiliary disease. Cancer Nurs 19(4):272-282. ease of the biliary tract. Murr MM et al: Pancreatic cancer.1991. Nurs- a person with acute pancreatitis? ing 26(4):33-39. female gender. Management of Persons vvith Problems of the Gallbladder and Exocrine Pancreas chapter42 1393 • Malabsorption is treated with the use of pancreatic enzyme • supplements. McConnell E. 1994. cholecystectomy include ineffective breathing pattern. developments. There is 13. 54(3):38-41. Foster PF: Nutritional support for the patient and fluid and electrolyte problems may be of concern. 3 Mr. It is not reversible. 11. and middle age. parenteral nutrition in mild acute pancreatitis. cholecystectomy. fluid resuscitation to prevent shock.1996. 14. 4. . Toskes PP: Acute pancreatitis':-medical management. 10. Fenster LF. 1993. Lewis LW: Managing the patient with pancreatitis. • Acute pancreatitis can result in criticai fluid and electrolyte 17. 23. Am • Most cases resolve spontaneously. Sidhu SS. 7. ed 4. Solie CJ: [nterpreting lab values in pancreatitis.1993. • Carcinoma of the biliary system is insidious and can be 15. use of birth control pills. Ann Intern Med 119(10): 1029-1035. resting the pancreas by 20.1993. 1994. metabolic disturbances. Greene LM. Payne RL. 1995. jective in patients with chronic pancreatitis. Ryan 77. National [nstitutes of Health: National [nstitutes of Health Consen- PANCREATIC DISORDERS sus Development Conference Statement on Gallstones and Laparo- • Pancreatitis may be acute or chronic. is being treated for acute pancreatitis re. transplant. McClave SA. Ghiloni BW: Cholelithiasis: current treatment options. of pancreatitis differs from acute alcohol-induced 3. and most patients eventually require liver early enteral vs. Baker CC. CARCINOMA OF THE BILlARY SYSTEM Nursing 21(11):98-102. Crit lated to biliary obstruction. Thompson C: Managing acute pancreatitis. Lonborg R.1995. ogy but frequently occurs in conjunction with IBD. CHOlEDOCHOllTHIASIS Crit Care Clin 11(2):295-306. 5. South Louisiana. Krumberger 1M: Acute pancreatitis. What may normally occur after the • Cancer of the pancreas is insidious and has a very poor remova I of her T-tube? What complication should the prognosis. Risk factors include obesity. Price P. lems. Malfertheiner P: Management of severe pancreatitis? acute pancreatitis. Peterson KJ. multipar- 8. Smith A: When the pancreas fails. Price TF. 1995. respond? 2 In what ways would your assessment findings for a References person with chronic pancreatitis differ from those for 1. J Am Board Fam Pract 8(1 ):22-28. Physician 48(5):762-768. Traverso LW: What symptoms does cholecystectomy cure? Am J Surg 169(5): 533-538. PRIMARY SClEROSING CHOLANGITIS 12. asymptomatic until late in the disease. and vomiting. Thirlby RC. [993. CA: Cancer J Clin 44(2):304-314. Huynh T: Acute pancreatitis-surgical management. Tandon RK: The pathogenesis of chronic pancreatitis. Am J Surg 165( 4): 390-398. Marshall JB: Acute pancreatitis: a review with an emphasis on new • Primary sclerosing cholangitis is usually idiopathic in etiol. Pain management is extremely difficult if the 1 Mrs. Spiro HM: Clinicai Gastroenterology. and pain. J Parenter Enteral Nutr 21(1): 14-20.1993. RN treatment of choice for gallbladder disease. Greifzo S. malabsorption and 22.1991. 24. and management of the T-tube. Everhart JE: Contributions of obesity and weight loss to gallstone disease. Snider HL: Comparison of the safety of no treatment. What aspect of this type Care Clin 11(2):311-322. Crit Care Nurs Clin North Am 5(1):37- • Patient problems requiring nursing attention after open 45. Forsmark CE. 1993. but the mortality from J Nurs 94(1l):45A-B. Arch Intern Med 153(6):1185-1193.1993. RN 55(3):52-54. • Biliary tract surgery by laparoscopic cholecystectomy is the 9. and collaborative monitoring for complications. steatorrhea and possibly diabetes mellitus. 56F. If acute cholecystitis occurs. McGraw • Abstinence from alcohol use is the primary treatment ob. 18.