18 Chapter 41Liver, Gallbladder, and Pancreatic Disorders
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 41.1
Slide 57
Liver Transplantation (cont.)
• Patient often has a T-tube, wound drainage devices, a nasogastric tube, and a central line
for total parenteral nutrition (TPN); mechanical ventilation used initially
• Assessments focus on neurologic status, vital signs, central venous pressure, respiratory
status, and indicators of bleeding
TALKING POINTS:
• What are some of the current medications used to prevent rejection of the donor liver?
• Before discharge, the patient should know signs and symptoms of transplant rejection and
infection, wound care, dietary restrictions (usually sodium restriction), and self-medication.
1
Bile
• Yellow-green liquid with important functions
Slide 59
Function
• Ducts deliver bile from the liver to the duodenum
• Bile produced in the liver and channeled into the common hepatic duct
• The common hepatic duct joins the cystic duct to form the common bile duct
Slide 60
Health History
• Digestive disturbances and pain
• Complete description of these symptoms
Slide 61
Physical Examination
• Significant findings on the physical examination include dry skin, fever, jaundice,
tachycardia, tachypnea, and abdominal guarding and distention
• See Box 41-2
2
Slide 62
Diagnostic Tests and Procedures
• Ultrasonography
• Oral cholecystography
• Intravenous cholangiography
__________________________________________ Chapter 41Liver, Gallbladder, and Pancreatic Disorders 19
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 41.1
3
Slide 63
Cholecystitis
• Inflammation of the gallbladder
• Caused by gallstones but can be due to bacteria, toxic chemicals, tumors, anesthesia,
starvation, and opioids
• Cystic duct may become occluded
Slide 64
Cholelithiasis
• Gallstones present
• May be found anywhere in the biliary tract: the gallbladder, the cystic duct, or the
common bile duct
TALKING POINTS:
• What are most gallstones composed of?
• It is not known exactly why gallstones form, but the process is associated with high
Slide 65
Cholecystitis and Cholelithiasis
• Signs and symptoms
• From mild indigestion to severe pain, fever, jaundice
• Also nausea, eructation, fever, chills, and right upper quadrant pain that radiates to
the shoulder
• Digestion of fats is impaired, causing intolerance of fatty foods and steatorrhea
TALKING POINTS:
• Symptoms typically occur about 3 hours after a meal, especially if the food had high fat
content.
• What is the usual color of the stool in a patient with cholelithiasis?
Slide 66
Cholecystitis and Cholelithiasis (cont.)
• Complications
• Pancreatitis, abscesses, cholangitis, and rupture of the gallbladder
• Medical diagnosis
• History and physical examination
• Fluoroscopy using contrast medium injected directly into the biliary tree
20 Chapter 41Liver, Gallbladder, and Pancreatic Disorders
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 41.1
Slide 67
Cholecystitis and Cholelithiasis (cont.)
• Medical treatment
• Analgesics, anticholinergics, and antibiotics
• Intravenous fluids
• Nasogastric tube
• Drug therapy
TALKING POINTS:
• What medication may be used to treat stones remaining in the common bile duct after a
cholecystectomy?
Cholecystectomy, Laparoscopic
• Surgeon inserts laparoscope with camera through small abdominal incision
TALKING POINTS:
• Why is it usually possible to discharge the patient within 24 hours?
• Swelling and obstruction of bile flow may result
Cholecystectomy, Classic Procedure
• Incision below right rib margin
• Gallbladder removed, common bile duct explored for stones
TALKING POINTS:
• How should the patient be positioned after surgery to promote drainage?
• Describe the care of the patient with a T-tube.
5
Slide 70
Cholecystitis and Cholelithiasis (cont.)
• Interventions
• Acute pain
• Deficient fluid volume
• Risk for impaired skin integrity
• Anxiety
• Risk for injury
Slide 71
Cholecystitis and Cholelithiasis (cont.)
• Postoperative interventions
__________________________________________ Chapter 41Liver, Gallbladder, and Pancreatic Disorders 21
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 41.1
3
Slide 72
Cancer of the Gallbladder
• Rare; thought to be related to chronic cholecystitis and cholelithiasis
• Diagnosis often delayed: signs and symptoms are same as for cholecystitis and
cholelithiasis
1
Slide 73
Anatomy and Physiology of the Pancreas
• A fish-shaped organ located in the upper left quadrant of the abdomen behind the
stomach
• Head of the pancreas lies against the duodenum, and the tail lies next to the spleen
TALKING POINTS:
• The pancreas is a gland that has both endocrine and exocrine functions.
• What is the difference between endocrine function and exocrine function?
Slide 74
Exocrine Function
• Carried out by acinar tissue
• Pancreatic fluid contains enzymes needed to digest proteins, fats, and carbohydrates
• Trypsin, amylase, and lipase
TALKING POINTS:
Endocrine Function
• Islets of Langerhans
• Alpha cells produce and secrete glucagon
TALKING POINTS:
• When is glucagon secreted?
• Insulin is secreted when the blood glucose rises, as after a meal.
Slide 76
• Obtain a complete description of any pain in the upper abdomen or epigastric area
• Functional assessment: dietary habits, alcohol use
Health History
• General health status
• May reveal previous disorders of the biliary tract or duodenum, abdominal trauma or
surgery, and metabolic disorders such as diabetes mellitus
22 Chapter 41Liver, Gallbladder, and Pancreatic Disorders
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 41.1
Physical Examination
• Restlessness, flushing, or diaphoresis during the examination
2
Slide 78
Diagnostic Tests and Procedures
• Imaging studies
• CT scan, endoscopic ultrasonography, MRI, PET, and ERCP
• Serum amylase, lipase, glucose, calcium, triglycerides
3
Slide 79
Pancreatitis
• Inflammation of the pancreas
• May be acute or chronic
• Caused by biliary tract disorders or alcoholism
Slide 80
Pancreatitis (cont.)
• Signs and symptoms
• Severe abdominal pain with sudden onset; centered in the upper left quadrant or the
epigastric region and radiating to the back
TALKING POINTS:
• Enzymes released into the abdominal cavity increase capillary permeability, permitting
protein-rich serum to leak from blood vessels; may cause cyanosis or greenish
discoloration of the abdominal wall, the flanks, and the area around the umbilicus.
• What are early signs and symptoms of shock?
__________________________________________ Chapter 41Liver, Gallbladder, and Pancreatic Disorders 23
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 41.1
Slide 81
Pancreatitis (cont.)
• Complications
• Pseudocyst, abscess, hypocalcemia, and pulmonary, cardiac, and renal complications
• Medical diagnosis
TALKING POINTS:
• Symptoms of pseudocyst include abdominal pain, nausea, vomiting, and anorexia.
Slide 82
Pancreatitis (cont.)
• Medical treatment
• Nothing by mouth
• Nasogastric tube
• Intravenous fluids
Slide 83
Pancreatitis (cont.)
• Medical treatment
• Drug therapy
• Analgesics, antispasmodics, anticholinergics, and gastric acid inhibitors
• Surgical intervention
• Endoscopic sphincterotomy followed by cholecystectomy
• Débridement
TALKING POINTS:
• The patient with chronic pancreatitis is likely to need to take pancreatic enzymes in order
to digest food.
• What symptom may be observed if there are inadequate pancreatic enzymes?
5
Pancreatitis (cont.)
• Assessment
• Assess for signs of hypovolemic shock
TALKING POINTS:
• What are some signs of hypovolemia?
24 Chapter 41Liver, Gallbladder, and Pancreatic Disorders
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 41.1
Slide 85
Pancreatitis (cont.)
• Interventions
• Acute pain
• Deficient fluid volume
• Risk for infection
• Deficient knowledge
3
Slide 86
Cancer of the Pancreas
• Quickly spreads to the duodenum, stomach, spleen, and left adrenal gland
• Risk factors: chronic pancreatitis and smoking
• Also high-fat diet, exposure to toxic chemicals
• Signs and symptoms
TALKING POINTS:
• About 42,000 new cases are diagnosed each year in the United States.
• What is the prognosis for a patient diagnosed with cancer of the pancreas?
Slide 87
Cancer of the Pancreas (cont.)
• Medical diagnosis
• Transabdominal ultrasound, computed tomography, MRI, ERCP, and endoscopic
ultrasonography
TALKING POINTS:
• Sometimes surgical procedures are done primarily to relieve obstruction and improve
patient comfort.
• What effect does radiation therapy have postoperatively?
5
Cancer of the Pancreas (cont.)
• Assessment
__________________________________________ Chapter 41Liver, Gallbladder, and Pancreatic Disorders 25
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 41.1
Slide 89
Cancer of the Pancreas (cont.)
• Interventions
• Acute pain
• Fear
Cancer of the Pancreas (cont.)
• Surgical complications
• Hemorrhage, fluid and electrolyte imbalances
Cancer of the Pancreas (cont.)
• Postoperative nursing care
Slide 92
Question 1
• _______ is a product of the normal breakdown of old red blood cells in the liver.
A. Bilirubin
B. Chyme
C. Pancreatinase
D. Phosphatase
TALKING POINTS:
Slide 93
Question 2
• Hepatitis _____ is transmitted from one person to another by way of water, food, or
medical equipment that has been contaminated with infected fecal matter.
A. A
B. B
C. C
D. D
TALKING POINTS:
26 Chapter 41Liver, Gallbladder, and Pancreatic Disorders
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 41.1
Activities
Classroom Choose from below to make 30 minutes
1
ASSESS BASELINE
• Have the class complete the Pretest. Collect
their work and use the results to guide how
you teach the class.
DISCUSS
• Discuss the various types of cells found in
the liver and their functions.
• Discuss the relationship of the liver to
discussion.
• Discuss factors that contribute to gallbladder
disease that should be considered when
taking a patient’s health history.
• Discuss the specific findings on physical
examination that may indicate gallbladder
disease.
PRACTICE
• In pairs, have students take turns practicing
a focused nursing assessment of a patient
with liver disease. The assessment should
include a review of the following:
• Medical history
• Family history
• Review of systems
• Functional assessment
__________________________________________ Chapter 41Liver, Gallbladder, and Pancreatic Disorders 27
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 41.1
2
DISCUSS
• Discuss what the patient will experience
during a liver biopsy.
• Discuss blood tests to assess liver and
gallbladder function and any special patient
preparation required before the tests.
• Discuss precautions a patient must follow
after having a liver scan.
• Discuss when and why intravenous
cholangiography might be used.
• Discuss why an allergy to seafood or iodine
is important to determine before having a
patient undergo some of the diagnostic
PRACTICE
• Before class, assign each student a different
radiologic, imaging, biopsy, or other
procedure used to evaluate liver disease.
Ask each student to investigate the nurse’s
role for each procedure and be prepared to
make a brief presentation to the class.
• Create a matching game on paper and hand
28 Chapter 41Liver, Gallbladder, and Pancreatic Disorders
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 41.1
3
DISCUSS
• Discuss the differences between the various
types of hepatitis.
• Discuss the possible origins of noninfectious
hepatitis.
cirrhosis of the liver.
• Discuss drug therapy for cirrhosis. What
drug classes are used and for what reason?
Is drug therapy directed at a cure or
treatment of symptoms?
• Discuss medical and psychological
implications of liver transplantation.
• Discuss the difference between cholecystitis
• Discuss under what circumstances
extracorporeal shock wave lithotripsy would
be used.
• Discuss nursing interventions for the patient
immediately following cholecystectomy.
• Discuss methods for helping the patient deal
• Discuss which blood level markers are used
to assess a patient with suspected
pancreatic disease. Are they specific for
pancreatic cancer?
• Discuss the various laboratory studies that
may be performed specifically for pancreatic
__________________________________________ Chapter 41Liver, Gallbladder, and Pancreatic Disorders 29
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 41.1
3
• Discuss common signs and symptoms of
PRACTICE
• Divide the class into small groups. Assign
each group one or more of the drug classes
used to treat cirrhosis. For the assigned
• As a class, discuss the pathophysiology,
signs and symptoms, diagnosis,
complications, and medical treatment of liver
cancer. Have students answer these
questions: Does cancer usually begin in the
liver? What are predisposing factors of liver
cancer? What diagnostic procedures are
used to confirm liver cancer?
• Divide the class into small groups. Have
each group discuss nursing interventions for
the following patients:
• A 40-year-old woman diagnosed with
cholelithiasis who has been prescribed
oral bile salts to dissolve gallstones
• A 60-year-old man who has undergone
abdominal surgery for cholelithiasis
• As a class, discuss the pathophysiology,
signs and symptoms, diagnostic testing,
complications, and medical treatment of
30 Chapter 41Liver, Gallbladder, and Pancreatic Disorders
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 41.1
3
• Present the following scenarios to the class.
• A patient with pancreatitis taking
meperidine for pain relief is sedated but
easily awakened.
• A patient with pancreatitis taking
propantheline bromide has a heart rate
For each of these situations, ask students
how the nurse should intervene for the
patient, if at all. Should the nurse be
concerned? Why or why not?
• Divide the class into several small groups.
Present the following scenario to the groups:
• A 65-year-old woman was recently
diagnosed with pancreatic cancer. She
is scheduled for a Whipple procedure in
the morning. She tells the nurse that the
4
DISCUSS
• Discuss the principle of esophageal-gastric
PRACTICE
• Lead a class discussion on the purpose and
nursing care of a patient with cirrhosis who
__________________________________________ Chapter 41Liver, Gallbladder, and Pancreatic Disorders 31
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 41.1
5
DISCUSS
• Discuss why patients with hepatitis often
have poor appetites and nursing
interventions to promote better nutrition.
• Discuss how ascites can affect respiratory
patterns.
• Discuss why a patient with pancreatitis is at
risk for developing an infection.
PRACTICE
• Divide the class into small groups. Have
each group modify nursing diagnoses, goals,
and interventions for the following patients:
• List key nursing diagnoses on the board that
may apply to the patient with liver disease.
• Divide the class into small groups. Have
each group identify nursing interventions for
the following patients:
• A 60-year-old man diagnosed with
chronic pancreatitis who abuses alcohol
• Divide the class into small groups. Have
each group modify nursing interventions for
the following patient scenario:
• A 70-year-old man is diagnosed with
32 Chapter 41Liver, Gallbladder, and Pancreatic Disorders
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 41.1
Critical Thinking Question
A patient who has end-stage liver disease is experiencing signs and symptoms of hepatic
encephalopathy. What interventions should the nurse implement for this patient? What
teaching should the nurse provide to the family?
Discussion Guidelines: The nurse must maintain safety for this patient by implementing
interventions that would prevent injury. This should include fall precautions and perhaps increased
supervision or more extensive measures. With hepatic encephalopathy, confusion is usually
present, although the severity may wax and wane. The patient may become agitated and require
Instructor Notes/Student Feedback
__________________________________________ Chapter 41Liver, Gallbladder, and Pancreatic Disorders 33
Introduction to Medical-Surgical Nursing, 6th ed.
41
Assessments for
Liver, Gallbladder, and Pancreas Disorders
CHAPTER OBJECTIVES
Lesson 41.1:
2. Identify the nurse’s role in tests and procedures performed to diagnose disorders of the liver,
gallbladder, and pancreas.
4. Describe the care of the patient who has an esophageal balloon tube in place.
5. Assist in developing a nursing care plan for the patient with liver, gallbladder, or pancreatic
dysfunction.
Assessments by Lesson & Objective
Lesson 41.1
1
Study Guide
• Part IA: 2, 4, 9, 10 (p. 259)
Evolve Instructor Resources
• Test Bank: 30, 31, 32
• Open Book Quiz: 1
Evolve Student Resources
• NCLEX Review: 9
2
Study Guide
• Part IA: 3 (p. 259)
Evolve Instructor Resources
• Test Bank: 1, 21, 29
• Open Book Quiz: 2
Evolve Student Resources
34 Chapter 41Liver, Gallbladder, and Pancreatic Disorders
Introduction to Medical-Surgical Nursing, 6th ed.
Assessments by Lesson & Objective
3
Study Guide
• Part IA: 1, 5-8 (p. 259)
• Part ID: 1-3 (p. 260)
Evolve Instructor Resources
• Test Bank: 2, 3, 8, 11, 12, 14, 17, 19, 20, 23-26, 28
• Open Book Quiz: 3-9
Evolve Student Resources
• NCLEX Review: 3, 6
• Prioritization: 1
4
Study Guide
• Part IIG: 10 (p. 263)
Evolve Instructor Resources
• Test Bank: 16
5
Study Guide
Evolve Instructor Resources
• Test Bank: 4-7, 9, 10, 13, 15, 18, 22, 27
• Open Book Quiz: 10
Evolve Student Resources
Instructor’s Notes/Student Feedback