Chapter 40
Assessment and Management
of Patients With Biliary
Disorders
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Cholelithiasis
• Pathophysiology
– Pigment stones
– Cholesterol stones
• Risk factors
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Cholelithiasis—Manifestations
• May have no or minimal symptoms and may be acute or
chronic.
• Epigastric distress: fullness, abdominal distention, vague upper
right quadrant pain. Distress may occur after eating a fatty
meal.
• Acute symptoms occur with obstruction and inflammation or
infection: fever, palpable abdominal mass, severe right
abdominal that radiates to the back or right shoulder, nausea
and vomiting.
• Biliary colic is episodes of severe pain usually associated with
nausea and vomiting, which usually occur several hours after a
heavy meal.
• Jaundice may develop due to blockage of the common bile
duct.
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Medical Management of Cholelithiasis
• Cholecystectomy
• Laparoscopic cholecystectomy
• Dietary management
• Medications: ursodeoxycholic acid and chenodeoxycholic
acid
• Nonsurgical removal
– By instrumentation
– Intracorporeal or extracorporeal lithotripsy
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Nonsurgical Techniques for Removing
Gallstones
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Laparoscopic Cholecystectomy
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Cholesterol Gallstones and Pigment
Gallstones
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Postoperative Care Interventions
• Low Fowler’s position
• May have NG
• NPO until bowel sounds return, then a soft, low-fat, high-
carbohydrate diet postoperatively
• Care of biliary drainage system
• Administer analgesics as ordered and medicate to
promote/permit ambulation and activities, including deep
breathing
• Turn, and encourage coughing and deep breathing,
splinting to reduce pain
• Ambulation
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Patient Teaching—See Chart 40-3
• Medications
• Diet: at discharge, maintain a nutritious diet and avoid
excess fat. Fat restriction is usually lifted in 4–6 weeks.
• Instruct in wound care, dressing changes, care of T-tube
• Activity
• Instruct patient and family to report signs of
gastrointestinal complications, changes in color of stool
or urine, fever, unrelieved or increased pain, nausea,
vomiting, and redness/edema/signs of infection at
incision site
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Pancreatitis
• A severe disorder that can lead to death. Acute
pancreatitis does not usually lead to chronic pancreatitis.
• Acute pancreatitis: the pancreatic duct becomes
obstructed and enzymes back up into the pancreatic
duct, causing auto digestion and inflammation of the
pancreas.
• Chronic pancreatitis: a progressive inflammatory disorder
with destruction of the pancreas. Cells are replaced by
fibrous tissue, and pressure within the pancreas
increases. Mechanical obstruction of the pancreatic and
common bile ducts and destruction of the secreting cells
of the pancreas occur.
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Manifestations
Acute Chronic
• Severe abdominal pain • Recurrent attacks of severe
upper abdominal and back
• Patient appears acutely ill pain accompanied by
vomiting
• Abdominal guarding
• Weight loss
• Nausea and vomiting
• Steatorrhea
• Fever, jaundice, confusion,
and agitation may occur
• Ecchymosis in the flank or
umbilical area may occur
• May develop respiratory
distress, hypoxia, renal
failure, hypovolemia, and
shock
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Nursing Process: The Care of the Patient
With Acute Pancreatitis—Assessment
• Focus on abdominal pain and discomfort
• Fluid and electrolyte status
• Medications
• Alcohol use
• GI assessment and nutritional status
• Respiratory status
• Emotional and psychological status of patient and family;
anxiety and coping
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Nursing Process: The Care of the Patient
With Acute Pancreatitis—Diagnoses
• Acute pain
• Ineffective breathing pattern
• Imbalanced nutrition
• Impaired skin integrity
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Collaborative Problems/Potential
Complications
• Fluid and electrolyte disturbances
• Necrosis of the pancreas
• Shock
• Multiple organ dysfunction syndrome
• DIC
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Nursing Process: The Care of the Patient
With Acute Pancreatitis—Planning
• Major goals include relief of pain and discomfort,
improved respiratory function, improved nutritional
status, maintenance of skin integrity, and absence of
complications.
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Relieving Pain and Discomfort
• Use of analgesics
• Nasogastric suction to relieve nausea and distention
• Frequent oral care
• Bed rest
• Measures to promote comfort and relieve anxiety
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Tumors of the Pancreas
• Pancreatic cysts
• Cancer of the pancreas
– Risk factors
– Sites of lesions
– Medical treatment
• Chemotherapy
• Radiation (limited)
• Surgery
– Treatment may be palliative
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Pancreatoduodenectomy
(Whipple’s Procedure)
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