Git Part 2-run

GIT part 2 Accessory Organs Ruby Ruth T. Roces, R.N., M.D.

Anatomy and Physiology Accessory Organs  Pancreas  Liver  Gall bladder

Pancreatic secretions

1. Bicarbonate 2. Pancreatic amylase 3. Pancreatic lipase 4. Trypsin and chymotrypsin

Liver physiology and Pathophysiology Normal Function

Abnormality in function

1. Stores glycogen

= Hypoglycemia

2. Synthesizes proteins

= Hypo-proteinemia

3. Synthesizes globulins

=Decreased Antibody formation  risk for INFECTION

4. Synthesizes Clotting factors

= Bleeding tendencies

5. Secreting bile

= Jaundice and pruritus

6. Converts ammonia to urea 7. Stores Vitamims and minerals

=Hyper-ammonemia

8. Metabolizes estrogen

= Gynecomastia, testes atrophy

=Deficiencies of Vit and min

Disorders

CONDITION OF THE LIVER Liver Cirrhosis 

A chronic, progressive disease characterized by a diffuse damage to the hepatic cells

CONDITION OF THE LIVER

Liver Cirrhosis ETIOLOGY: Post-infection, Alcohol (Laennac’s cirrhosis), Cardiac diseases, Schisostoma, Biliary obstruction

Pathogenesis: 

repeated destruction of hepatic cell

→ scar tissue formation (fibrotic) → regeneration of liver cell follows → another destruction will occur → cycle (scarring and regeneration) will be repeated until hepatocytes becomes fibrotic and liver function is

CONDITION OF THE LIVER ASSESSMENT FINDINGS  1. Anorexia and weight loss  2. Jaundice  3. Fatigue

CONDITION OF THE LIVER ASSESSMENT FINDINGS  4.

Early morning nausea and vomiting  5. RUQ abdominal pain  6. Ascites  7. Signs of Portal hypertension

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Liver function test: Elevated AST aspartate aminotransferase formerly SGOT 4.8 - 19 U/L Elevated ALT alanine aminotransferase formerly SGPT 2.4 - 7 U/L highly specific Elevated Alkaline Phosphatase-30115 IU Elevated Bilirubin -0.1-1.0 mg/dL

COMMON LABORATORY PROCEDURES Liver biopsy 

Intratest – Position: Semi fowler’s LEFT lateral to expose right side of abdomen Post-test: position on RIGHT lateral with pillow underneath, monitor VS and complications like bleeding, perforation. Instruct to avoid lifting objects for 1 week

CONDITION OF THE LIVER NURSING INTERVENTIONS  1.

Monitor VS, I and O, Abdominal girth, weight, LOC and Bleeding  2. Promote rest. Elevated the head of the bed to minimize dyspnea

CONDITION OF THE LIVER NURSING INTERVENTIONS  3. Provide Moderate to LOWprotein (1 g/kg/day) and LOWsodium diet  4. Provide supplemental vitamins (especially K) and minerals  Administer prescribed Diuretics= to reduce ascites and edema Lactulose= to reduce NH4 in the bowel Antacids and Neomycin= to kill

CONDITION OF THE LIVER NURSING INTERVENTIONS 6. Avoid hepatotoxic drugs – Paracetamol – Anti-tubercular drugs 7. Reduce the risk of injury – Side rails reorientation – Assistance in ambulation – Use of electric razor and softbristled toothbrush

CONDITION OF THE LIVER

NURSING INTERVENTIONS 

8. Keep equipments ready including SengstakenBlakemore tube, IV fluids, Medications to treat hemorrhage

Wilson’s disease Rare autosomal-recessive disorder  Excessive deposition of copper in the liver & brain  < 30 y.o.  Defect in chromosome 13copper transporting protein 

Assessment Liver abnormalities  Jaundice Neurologic  Loss of coordination  Tremor  Dysphagia

Psychiatric abnormalities  Psychosis  Mania  depression  Anxiety 

Kayser-Fleischer rings in the cornea

Diagnostics  Decreased

serum ceruloplasmin  Elevated urinary copper excretion  Elevated hepatic copper

Management 

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Dietary copper restriction (shellfish,liver,legumes) Penicillamine (copper chelator), administered w/ pyridoxine Oral zinc ( inc fecal excretion)

Gall bladder

Cholelithiasis  Formation

of GALLSTONES in the biliary apparatus

Predisposing FACTORS

“ 5 F’s”  Female  Fat  Forty  Fertile  Fair

Assessment findings

Asymptomatic in 80% PE:  RUQ tenderness  Palpable gallbladder 

Diagnostics 

Ultrasound may show the gallstones (95%)

Management Cholecystectomy- definitive & curative  Dietary modification  Pharmacologic dissolution( w/ bile salts) w/ or w/o lithotripsy 

CONDITION OF THE GALLBLADDER Cholecystitis  Inflammation of the gallbladder  Can be acute or chronic  Can be calculous or acalculous

Pathophysiology Supersaturated bile, Biliary stasis Stone formation Blockage of Gallbladder Inflammation, Mucosal Damage and WBC infiltration

CONDITION OF THE GALLBLADDER ASSESSMENT findings for cholecystitis 1. Charcot’s triad 2. Indigestion, belching and flatulence 3. Fatty food intolerance

CONDITION OF THE GALLBLADDER

ASSESSMENT findings for cholecystitis 4. Mass at the RUQ 5. Murphy’s sign

CONDITION OF THE GALLBLADDER 

DIAGNOSTIC PROCEDURES

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Ultrasonographycan detect the stones  2. Abdominal X-ray  3. Cholecystography

CONDITION OF THE GALLBLADDER 

DIAGNOSTIC PROCEDURES

 4.

WBC count increased  5. HIDA scan- cannot visualize the gallbladder+  6. ERCP: revels inflamed gallbladder with gallstone

ERCP

CONDITION OF THE GALLBLADDER

NURSING INTERVENTIONS  1. NPO in the active phase  2. Maintain NGT decompression 

3. give pain med- Demerol (MEPERIDINE)

CONDITION OF THE GALLBLADDER 

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4. AVOID HIGH- fat diet and GASforming foods 5. Assist in surgical and nonsurgical measures 6. Surgical proceduresCholecystectomy, Choledochotomy, laparoscopy

CONDITION OF THE GALLBLADDER 

2. 3.

4. 5.

PHARMACOLOGIC THERAPY Analgesic- Meperidine Chenodeoxycholic acid= to dissolve the gallstones Antacids Anti-emetics

CONDITION OF THE GALLBLADDER

Post-operative nursing interventions  

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1. MONITOR 2. Post-operative position- LOW FOWLER’s 3. Encourage early ambulation 4. Administer medication before coughing and deep breathing exercises.Advise client to splint during exercise.

CONDITION OF THE GALLBLADDER

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5. Administer analgesics, antiemetics, antacids 6. Care of the biliary drainage or T-tube drainage ( 200300ml) 7. Fat restriction is only limited to 4-6 weeks. Normal diet is resumed

Cholangitis  Infection/inflammation

of biliary tree 2 to obstruction (stone or malignancy)

Assessment  Charcot’s

triad  Reynold’s pentad ( charcot’s plus shock & altered mental status)

Diagnostics  WBC  Bilirubin,

alk phosphate- inc  Blood cultures- ( gm – enterics)  ERCP- diagnostic gold standard

Management  Life

threatening- ICU  Iv antibiotics  Bile duct decompressionendoscopic sphicterotomy, pecutaneous hepatic drainage or operative decompression  ERCP- stone removal, stent

Pancreas

CONDITION OF THE PANCREAS

Pancreatitis Inflammation of the pancreas Can be acute or chronic

Etiology & Risk Factors – Alcoholism – gallstones – Hypercalcemia – Trauma – Viral infections – Post ERCP

– Hyperlipidemia – Drugs(thiazide)

CONDITION OF THE PANCREAS PATHOPHYSIOLOGY of acute pancreatitis 

Spasm, edema or block in the Ampulla of Vater reflux of proteolytic enzymes auto digestion of the pancreas inflammation

PATHOPHYSIOLOGY Autodigestion of pancreatic tissue Hemorrhage, Necrosis and Inflammation KININ ACTIVATION will result to increased permeability Loss of Protein-rich fluid into the peritoneum HYPOVOLEMIA

CONDITION OF THE PANCREAS

ASSESSMENT findings  1. Abdominal painacute onset, occurring after a heavy meal or alcohol intake

CONDITION OF THE PANCREAS ASSESSMENT findings  3. Bruising on the flanks and umbilicus

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Grey turner’s sign-purplish discoloration of the flank (ecchymoses) Cullen’s sign-periumbilical discoloration

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Hypotension and hypovolemia  6. Signs of shock  7. Client assumes fetal position to relieve pressure (celiac plexus nerve)

CONDITION OF THE PANCREAS DIAGNOSTIC TESTS 

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1. Serum amylase and serum lipase- inc 3x 2. Ultrasound 3. WBC- inc 4. Serum calcium-dec.- binds w/ area of necrosis 5. CT scan

CONDITION OF THE PANCREAS NURSING INTERVENTIONS  Demerol is given. Morphine is AVOIDED  correction of Fluid and Blood loss  Place patient on NPO to inhibit pancreatic stimulation  NGT insertion to decompress distention and remove gastric

CONDITION OF THE PANCREAS NURSING INTERVENTIONS 

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Position patient in SEMIFOWLER’s to decrease pressure on the diaphragm Deep breathing and coughing exercises Provide parenteral nutrition

CONDITION OF THE PANCREAS NURSING INTERVENTIONS 

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Introduce oral feedings gradually- HIGH carbo, LOW FAT Maintain skin integrity Manage shock and other complications

Pancreatic Cancer Usually an adenocarcinoma  Usually involves the Head Risk factors:  Smoking  High fat diet  Men 

Assessment  Abdominal

pain radiating to the back  Anorexia  N/V  Weight loss  Weakness, fatigue  Indigestion

Jaundice (obstructs the bile duct)  Trousseau’s signmigratory thrombophlebitis d/t ectopic production of procoagulatants  Courvoisier’s signpalpable nontender 

Diagnostics  CT

scan  ERCP  Transcutaneous pancreatic biopsy- risk of spreading tumor

Management  Surgery-

whipples procedure (pancreaticoduodenecto my)  Radio/chemo