Prepared by:

Dr. PA Maroma
 “gallstones”
 FAT, FEMALE,
FORTY, FERTILE
• More common in
women after age 40
(estrogen therapy),
women taking oral
contraceptives, and in
the obese
Cholecystitis
• acute or chronic
inflammation of the
gallbladder
Theory of Stone formation:
Metabolic factors (obesity, pregnancy, DM,
hypothyroidism,stasis) MAY all lead to stagnation of bile in
the gallbladder

excessive absorption of water

precipitation of salts (stones)

 Gallstones are composed primarily of cholesterol (80%),

bile salts, Ca++, bilirubin & CHONs
Assessment findings
• Most patients are asymptomatic.
• When symptomatic; PAIN in RUQ and
epigastric pain lasting approximately 30 min.
• Fever & leukocytosis (WBC)
• Charcot triad
 fever, jaundice, pain in RUQ pain (ascending
cholangitis)
Assessment findings
• Intolerance for fatty foods (steatorrhea, N&V,
sensation of fullness)
• Pruritus, easy bruising, dark amber urine

Diagnostic tests
• Direct bilirubin transaminase, alkaline
phosphatase, WBC, amylase, lipase: all
increased
• Oral cholecystogram (gallbladder series):
positive for gallstone
Nursing interventions
• Administer pain medications as
ordered and monitor for effects.
• Administer IV fluids as ordered.
• Provide small, frequent meals of
modified diet, low fat (if oral intake
allowed)
• Provide care to relieve pruritus
• Provide care for the client with a
cholecystectomy or
choledochostomy
Medical management
 Supportive treatment: NPO with NG

intubation and IV fluids

 Diet modification with administration of

fat- soluble vitamins

 Drug therapy

• Narcotic analgesics (Demerol is the

drug of choice) for pain
• Morphine sulfate is contraindicated
because it causes spasms of the
sphincter of Oddi
Medical management
 cont… Drug therapy

• Anticholinergics (atropine) may be used for

pain
• Antiemetics
 Surgery

• Cholecystectomy
• Choledochostomy
• Choledochotomy
 Cholecystectomy
• removal of the gallbladder with insertion of a T-tube into the
common bile duct if common bile duct exploration is
performed
 Choledochotomy
• opening of common duct, removal of stone, and insertion of a
T-tube
 Laparoscopic Cholecystectomy
• performed via laparoscopy for uncomplicated cases when
client has not had previous abdominal surgery
 Cholecystostomy
• opening of the gallbladder to remove stones
Nursing interventions:
 Provide routine pre-op care
 Provide routine post-op care
 Position client in semi-Fowler’s or side-lying
positions; reposition frequently.
 Splint incision when turning, coughing, and deep
breathing
 Maintain/monitor functioning of T-tube
• Ensure that T-tube is connected to closed
gravity drainage.
• Avoid kinks, clamping, or pulling of the tube.
Nursing interventions
 cont… Maintain/monitor functioning of T-tube
• Measure and record drainage every shift
• Expect 300 – 500 ml bile-colored drainage for the 1st
24° then 200 ml/24° for 3 - 4 days
• Assess for signs of peritonitis
• Monitor color of urine and stools (stools will be light
colored if bile is flowing through T tube but normal
color should reappear as drainage diminishes)
• Assess skin around T-tube; cleanse frequently and keep
dry
 Provide client teaching and discharge planning
concerning
• Adherence to dietary restrictions
• Resumption of ADL
 avoid heavy lifting for at least 6 weeks
 resume sexual activity as desired unless ordered
otherwise by physician
 clients having laparoscopy cholecystectomy usually
resume normal activity within two weeks
• Recognition and reporting of signs of complications (fever,
jaundice, pain, dark urine, pale stools, pruritus)
• An inflammatory process with varying degrees
of pancreatic edema, fat necrosis, or hemorrhage
• Proteolytic and lipolytic pancreatic enzymes are
activated in the pancreas rather than in the
duodenum, resulting in tissue damage and
autodigestion of the pancreas
• Occurs most often in the middle aged
Causes:
• Alcoholism/ alcohol abuse
• Biliary tract disease/ biliary obstruction
• Trauma, viral infection, penetrating duodenal
ulcer, abscesses
• Drugs (antihypertensives, steroids, thiazide
diuretics, antimicrobials, immunosuppressives,
oral contraceptives)
• Metabolic disorders (hyperparathyroidism,
hyperlipidemia)
• Unknown/ autoimmune
Assessment findings
• Pain (LUQ radiating to back, flank, or substernal
area) accompanied by DOB (shallow respiration
with pain), aggravated by eating
• N&V, decreased/absent bowel sounds,
• Abdominal tenderness w/ muscle-guarding
• (+) Grey Turner’s spots (ecchymoses on flanks)
• (+) Cullen’s sign (ecchymoses of periumbilical area)
• Tachycardia
Diagnostic tests
 Serum amylase (>300
somogyi units) & lipase
 urinary amylase
 blood sugar
 lipid levels
 Serum calcium
• CT scan: enlargement of
the pancreas
Nursing interventions:
• Administer analgesics, antacids, and anticholinergics as
ordered, monitor effects
• Withhold food/fluid and eliminate odor and sight of food from
environment to decrease pancreatic stimulations
• Maintain NGT and assess for drainage.
• Institute Non-pharmacologic measures to decrease pain.
 Assist client to positions of comfort (knee chest, fetal
position)
 Teach relaxation techniques and provide a quiet, restful
environment.
 Provide client teaching and discharge planning
concerning
• Dietary regimen when oral intake permitted
 High CHO, high CHON, low-fat diet
 Eating small, frequent meals instead of three
large ones
 Avoiding caffeine products
 Eliminating alcohol consumption
 Maintaining relaxed atmosphere after meals
 cont… Provide client teaching & discharge planning
concerning
• Recognition/reporting of signs of complications
 Continued N&V
 Abdominal distension with increasing fullness
 Persistent weight loss
 Severe epigastric or back pain
 Frothy/foul-smelling bowel movements
 Irritability, confusion, persistent elevation of
temperature (2 days)
Medical management:
 Drug therapy

• Analgesics (Demerol) to relieve pain.

MORPHINE is avoided because it can cause
spasm of the sphincter aggravating pain
• Smooth-muscle relaxants to relieve pain
 papaverine, nitroglycerin
• Anticholinergics to decrease pancreatic
stimulation
 atropine, propantheline bromide
Medical management:
• cont… Drug therapy
 Antacids to decrease pancreatic stimulation
 H2-antagonists, vasodilators, calcium gluconate

• Diet modification
• NPO usually for a few days to promote GIT rest
• Peritoneal lavage
• Dialysis if the condition is severe
 Infectious inflammation of the liver parenchyma
caused by bacteria, viruses and other
microorganisms.
• widespread inflammation of the liver tissue
• liver cell damage due to hepatic cell degeneration and
necrosis
• proliferation and enlargement of the Kupffer cells
• inflammation of the periportal areas causing interruption
of bile flow
 ssRNA virus
transmitted via fecal-
oral route.
 Poor hygiene or
contaminated food and
shellfish increase risk
of transmission
 Incubation period: 15 –
45 days
 DNA virus, identified in all body fluids: blood, saliva,
synovial fluid, breast milk, ascites, cerebral spinal fluid,
etc.
 Transmitted by blood and body fluids (saliva, semen,
vaginal secretions): often from contaminated needles
among IV drug abusers; intimate/sexual contact
 accounts for 50% of cases of fulminant hepatitis
 In an adult who develops acute hepatitis B, there is
approximately 10% chance that it will progress into chronic
hepatitis; in the neonate the chance is 90% for chronic
hepatitis.
 Incubation period is very long: 1 - 6 months
 ssRNA virus generally transmitted predominantly by
blood products
 Currently the most common hepatitis among IV drug
abusers and in prisons
 Before 1990 it accounted for 90% of transfusion
hepatitis
 Incubation: 2 weeks - 6 months
 high risk of progression to chronic form (70 – 80%)
 associated with extrahepatic manifestations commonly:
mixed cryoglobulinemia and polyarteritis nodosa
 RNA virus that infects either simultaneously with hepatitis
B or as a super-infection in a person with chronic hepatitis B
 Hepatitis D infection cannot occur unless there is current
and ongoing replication of the hepatitis B virus
 Overall, this infection carries the highest risk among acute
viral hepatitis for fulminant disease; the risk is even greater
in super-infection
 Predominantly seen in patients exposed to blood products
(drug addicts and hemophiliacs). If anti-HBs antibodies are
present, then that person is immune to hepatitis B and D
 Similar to Hepatitis A
with fecal or oral
transmission, there is
no chronic form
 The risk of fulminant
disease has been
described mainly in
pregnant patients
Assessment findings
 Preicteric stage (prodromal phase) = 1 week
• Anorexia (major manifestation), N&V, fatigue, constipation or
diarrhea, weight loss
• RUQ discomfort, hepatomegaly, splenomegaly, lymphadenopathy
 Icteric stage
• Fatigue, weight loss, light-colored stools, dark urine
• Continued hepatomegaly with tenderness, lymphadenopathy,
splenomegaly
• Jaundice, pruritus
 Posticteric stage
• Fatigue, but an increased sense of well-being, hepatomegaly
gradually decreasing
Collaborative Management
• Promotion of rest to relieve fatigue
• Maintenance of food and fluid intake
• 3,000 ml/day of fluids for fever and vomiting;
monitor I and O, weight
• Well – balanced diet; encourage fruit juices and
carbonated beverages
• Fats may need to be restricted
• Alcoholic beverages should be avoided
• Prevention of injury
cont… Collaborative Management
• Monitor PT (bleeding tendencies): plan so that
all blood samples are collected at one time to
avoid several punctures
 avoid parenteral injections, if possible
 apply pressure to injection sites and venipuncture sites
for 5 minutes
• Monitor Hgb/Hct, urine and stools for fresh or
old blood; the skin for petechiae
cont… Collaborative Management
• advise client to use soft toothbrush or swabs
• administer Vitamin K as ordered
• Provision of comfort measures
• Relaxing baths, backrubs, fresh linens and quiet
dark environment
cont… Collaborative Management
 Relieve pruritus through the following measures:
• Use of cool, light, non-restrictive clothing
• Use of soft, dry, clean bedding, use of warm baths
• Application of emollient creams and lotions to dry
skin.
• Maintenance of a cool environment
• Administration of antihistamines as ordered
• Use of diversional activities, e.g. reading, TV and
radio
 Chronic, progressive disease characterized by
inflammation, fibrosis, and degeneration of the liver
parenchymal cells
 Destroyed liver cells are replaced by scar tissue,
resulting in architectural changes & malfunction of
the liver
Types
• Laênnec’s cirrhosis
 associated with alcohol abuse and malnutrition;
characterized by an accumulation of fat in the
liver cells, progressing to widespread scar
formation.
• Postnecrotic cirrhosis
 results in severe inflammation with massive
necrosis as a complication of viral hepatitis.
cont… Types
• Cardiac cirrhosis
 occurs as a consequence of RSHF; manifested
by hepatomegaly with some fibrosis.
• Biliary cirrhosis
 associated with biliary obstruction, usually in the
common bile duct; results in chronic impairment
of bile excretion
 Fatty Liver
Normal Liver Liver cirrhosis caused
by alcoholism
Assessment:
• Anorexia, weakness, weight loss (liver is unable to metabolize
nutrients and store fat-soluble vitamins)
• Fever (in response to tissue injury)
• Jaundice, pruritus, tea colored urine (due to bilirubin in the
blood)
 remember!!! bilirubin is conjugated initially before
excretion
• Increased Bleeding tendencies. (liver is unable to store Vit. K.
There is also impaired production of clotting factors)
• Portal HPN
Pathology:
 In portal hypertension
• plasma shift into interstitial spaces within the liver due to the
increase pressure. The collection of fluids shifts out of the
Glisson’s capsule and accumulate in the peritoneal cavity
 The liver is unable to metabolize protein, thereby
hypoalbuminemia occurs
• result to decreased oncotic pressure, fluids shift out of the
IVC, and accumulate in the peritoneal cavity.
Pathology:
 The liver is unable to excrete adrenal cortex

hormone, one of which is aldosterone

• Hyperaldosteronism leads to retention of sodium and water
 Esophageal varices = 2° to backpressure
 Internal hemorrhoids, leg varicosities, and dependent
edema
• due to venous stasis, increasing hydrostatic pressure. This
leads to shifting of plasma into interstitial space
 Consequences of Portal HPN:
• Hepatomegaly= initially, then the liver shrinks in size as
fibrosis replaces the liver parenchyma
• Splenomegaly= due to increased backpressure of the blood
• Caput medusae (dilated veins over the abdomen)
• Spider angioma (telangiectasia / dilated capillaries over the
face and anterior trunk)= due to increased estrogen
• Palmar erythema. This is also due to elevated estrogen level
in males.
• Ascites
 Males (estrogen) will result to:
• Decreased libido, Impotence, Fall of body hair, Atrophy of
testicles, gynecomastia
 Females (androgen)
• Hirsutism
• acne
• deepening of voice
• Virilism (development
or premature
development of male
secondary sexual
characteristics)
HEPATIC ENCEPHALOPATHY
 Accumulation of AMMONIA because the liver cannot
convert ammonia into urea that can lead to hepatic coma
(Ammonia is by product of CHON metabolism)
 initial manifestations: BEHAVIORAL changes and
MENTAL changes
 Other findings in advanced stages are:
• asterixis – flapping tremors of the hands
• confusion / disorientation
• delirium / hallucination
• fetor hepaticus - disagreeable odor from the mouth
• coma
Diagnostic tests
• SGOT or AST, SGPT, LDH, alkaline phosphatase
increased
• Serum bilirubin increased
• PT prolonged
• Serum albumin decreased
• Hgb/Hct decreased
• BSP increased
Nursing interventions
 Provide sufficient rest and comfort
• Provide bed rest with bathroom privileges.
• Encourage gradual, progressive, increasing activity with
planned rest periods.
• Institute measures to relieve pruritus.
 Do not use soaps and detergents
 Bathe in tepid water followed by application of an
emollient lotion.
 Provide cool, light, nonrestrictive clothing.
 Keep nails short to avoid skin excoriation from
scratching.
 Apply cool, moist compresses to pruritic areas.
cont… Nursing interventions
 Promote nutritional intake
• Encourage small frequent feedings.
• Promote a high-calorie, low- to moderate- protein, high
CHO, low-fat diet, with supplemental vitamin therapy
(vitamins A, B- complex, C, D, K, and folic acid)
 Prevent infection
• Prevent skin breakdown by frequent turning and skin care.
• Provide reverse isolation for clients with severe
leukopenia; pay special attention to hand-washing
technique.
• Monitor WBC.
 Monitor/prevent bleeding.
cont… Nursing interventions
 Administer diuretics as ordered
 Provide client teaching & D/C planning concerning:
• Avoidance of agents that may be hepatotoxic (sedatives, opiates, or OTC
drugs detoxified by the liver)
• How to assess for weight gain and increased abdominal girth
• Avoidance of persons with upper respiratory infections
• Recognition and reporting of signs of recurring illness (liver tenderness,
increased jaundice, increased fatigue, anorexia)
• Avoidance of all alcohol
• Avoidance of straining at stool, vigorous blowing of nose and coughing, to
decrease the incidence of bleeding
 Local or generalized inflammation of part or all of the
parietal and visceral surfaces of the abdominal cavity
Pathology:
• Initial response
 edema, vascular congestion, hypermotility of the bowel
and outpouring of plasma-like fluid from the
extracellular, vascular, and interstitial compartments into
the peritoneal space
• Later response
 abdominal distension leading to respiratory compromise,
hypovolemia results in decreased urinary output
• Intestinal motility gradually decreases and progresses to
paralytic ileus
Causes
• Caused by trauma (blunt or penetrating)
• Inflammatory conditions
 ulcerative colitis, diverticulitis, pelvic inflammatory
disease
• Ischemia
• Ruptured appendix
• Perforated peptic ulcer
• UTI
• Bowel obstruction (volvulus, intestinal obstruction)
• Bacteria invasion
Assessment findings
 Severe abdominal PAIN, rebound tenderness, muscle
rigidity, absent bowel sounds, abdominal distension
 Anorexia, N&V
 Shallow respirations; decreased urinary output; weak, rapid
pulse; fever
 Signs of shock
• Tachycardia, Tachypnea, Oliguria, Restlessness, Weakness,
Pallor, Diaphoresis
 Diagnostic tests
• WBC elevated WBC (20,000/cu. mm. or higher)
• Hct elevated (if hemoconcentration)
Management
• NPO with fluid replacement
• Drug therapy: antibiotics to combat
infection, analgesics for pain
• NGT is inserted to relieve abdominal
distention
• Peritoneal lavage with warm saline
• Insertion of drainage tubes
• Fluid, electrolyte and colloid replacement,
TPN solutions
 Surgery
• Laparotomy: opening made through the abdominal wall into the
peritoneal cavity to determine the cause of peritonitis
• Depending on cause, bowel resection may be necessary
Nursing interventions
 Assess respiratory status for possible distress.
 Assess characteristics of abdominal pain and changes
over time.
 Administer medications as ordered.
 Perform frequent abdominal assessment
 Monitor and maintain F&E balance; monitor for signs
of septic shock.
 Maintain patency of NG or intestinal tubes
 Encourage deep breathing exercises
 Place client in Fowler’s position to localize peritoneal
contents
 Provide routine pre- and post-op care if surgery
ordered