Learning Objectives
By the end of this section, you will be able to:
- Discuss the pathophysiology, risk factors, and clinical manifestations of hepatic and biliary disorders
- Describe the diagnostics for and laboratory values monitored in the management of hepatic and biliary disorders
- Apply nursing concepts and plan associated nursing care for the patient with hepatic and biliary disorders
- Evaluate the efficacy of nursing care for the patient with hepatic and biliary disorders
- Describe the medical therapies that apply to the care of hepatic and biliary disorders
The liver plays a critical role in the body. It contributes to metabolism, storage of fat-soluble vitamins, protein synthesis, detoxification, and bile production. Bile helps the body digest fats. The pancreas assists in regulation of blood sugar and in digestion of food. This section discusses jaundice, ascites, liver failure, cirrhosis, hepatic encephalopathy, pancreatitis, and pancreatic cancer.
Manifestations of Liver Dysfunction
Manifestations of liver dysfunction are jaundice, hemolytic jaundice, hepatocellular and obstructive jaundice, and portal hypertension.
Jaundice
Jaundice occurs when skin and sclera (whites of the eyes) (Figure 19.17) turn yellow as a result of too much bilirubin in the body. Bilirubin is a yellow chemical in hemoglobin, the substance that carries oxygen in red blood cells. As red blood cells break down, the old ones are processed by the liver. If the liver cannot properly process the old blood cells, bilirubin builds up and causes the skin and sclera to appear yellow. New onset of jaundice should always be reported to the health care provider. Jaundice can be classified into three types: hemolytic (prehepatic), hepatocellular (hepatic), and obstructive (posthepatic). For nursing care consideration, the nurse is to monitor the underlying cause for the jaundice and report any changes in patient condition or worsening jaundice.
Hemolytic Jaundice
Hemolytic occurs when there is excessive red blood cell break down that overwhelms the ability of the liver to process the breakdown. It is commonly seen in newborns and resolves rapidly. In adults, the causes can include penicillin, inherited blood disorders (sickle cell anemia or thalassemia), Escherichia coli infections, blood transfusion complications, bone marrow failure, and autoimmune conditions. In this instance, the nurse will continue to monitor hemolytic parameters and manage underlying causes to reduce hemolysis.
Hepatocellular and Obstructive Jaundice
Hepatocellular jaundice is a sign of dysfunction of the liver cells and indicates the liver is not properly conjugating bilirubin. Causes include infection, alcoholic liver disease, hereditary or autoimmune conditions, and cancer. Obstructive jaundice is caused by an obstruction preventing biliary drainage. The most common cause of obstructive jaundice is a gallstone blocking the common bile duct, but it can also be caused by certain cancers, strictures, or drug-induced cholestasis (Teach Me Surgery, 2022).
Portal Hypertension
Another liver condition, portal hypertension, is an increase in pressure within the portal venous system because of resistance to portal blood flow. This is often caused within the liver from cirrhosis, or outside the liver from thrombosis or pericarditis (Oliver et al., 2023). This increased pressure can cause varices (abnormal dilation of the veins) in the stomach (Figure 19.18), esophagus, spleen, and pancreas. Without treatment, portal hypertension can cause complications such as variceal bleeding, ascites, hepatorenal syndrome, infection, and cardiomyopathy.
Ascites
Ascites is an accumulation of fluid in the peritoneal cavity (Figure 19.19) that is caused by cirrhosis of the liver. Less than 2 percent of the population is diagnosed with liver disease. Ascites can cause discomfort and affect the patient’s quality of life as it progresses.
Nursing Care of the Patient with Ascites
Nursing care for the patient with ascites includes monitoring for complications, patient education, and assistance with treatment ordered. These include
- administering medications
- documenting daily weights and abdominal girth measurement
- educating patients
- monitoring laboratory values, such as sodium levels
- monitoring vital signs and intake and output
Recognizing Cues and Analyzing Cues
Physical assessment findings may include jaundice, bruises, muscle wasting, peripheral edema, tachypnea, and abdominal distention and tenderness. Vital signs may reveal tachypnea. Provide oxygen as ordered and appropriate.
Prioritizing Hypotheses, Generating Solutions, and Taking Action
Signs of respiratory distress and inadequate oxygenation are a high priority. Lack of ability to take deep breaths can cause the patient to develop pneumonia. Encourage the patient to use an incentive spirometer and perform cough and deep breathing exercises while lying in bed to clear mucosal secretions and prevent pneumonia. Assist with obtaining any laboratory studies or blood cultures ordered, as appropriate.
Evaluation of Nursing Care and Outcomes for the Patient with Ascites
Symptom improvement is a sign of effective nursing care. The patient should have a decrease in abdominal growth, decrease in pain, improved oxygenation, and stable vital signs. It is important to monitor interventions and adjust as necessary to meet goals. The primary patient outcome related to ascites management is treatment of the underlying cause and reduction of ascites. The patient reporting an improvement in symptoms, improved laboratory studies, and the patient demonstrating knowledge of their disorder and the importance of treatment compliance are all indications of positive outcomes.
Medical Therapies and Related Care
A sodium-restricted diet will help control fluid retention. A dietitian will also be involved in the patient’s care to help create a healthy meal plan that is low in sodium. Diuretics may also be prescribed to limit fluid retention. A paracentesis may need to be done periodically to remove ascetic fluid. A transjugular intrahepatic portosystemic shunt (TIPS) procedure may be performed in advanced cases of liver disease to lower portal vein pressure and decrease fluid buildup (Figure 19.20).
Liver Disease
Any condition that causes damage to the liver and prevents it from properly functioning is called liver disease. Liver disease can be acute (occur over days or weeks) or chronic (occur gradually over months or years). In the United States, liver disease is the twelfth leading cause of death (American Liver Foundation, 2022). Chronic liver disease progresses in four stages: inflammation, fibrosis, cirrhosis, and end-stage liver disease (ESLD). Once ESLD occurs, the liver no longer can function or heal itself. Liver disease is caused by conditions, such as hepatitis (Table 19.9) or other viral infections, cancer, toxins, genetic conditions, and autoimmune disorders. Inflammation of the liver caused by exposure to drugs, alcohol, toxins, or autoimmune disease is called nonviral hepatitis; viral hepatitis is inflammation of the liver caused by a virus. The most common types of viral hepatitis are A, B, C, D, and E.
| Hepatitis Virus Type | Cause | Symptoms | Treatment |
|---|---|---|---|
| C | Exposure to blood or semen of an infected person; commonly transmitted through needle sharing from drug use or tattoos; can also be transmitted to an infant born to an infected mother | Occur 2–12 weeks after exposure; can include
|
95% curable within 2–3 months with medications |
| D | Can only infect a patient who already has hepatitis B virus infection (called superinfection) or by being exposed to both simultaneously (called coinfection); transmitted through blood or body fluids | Occur 3–7 weeks after infection; can include
|
There is no cure; treatment is based on supportive care. |
| E | Fecal-oral route; transmitted by consuming contaminated or uncooked meats, such as pork, boar, venison, or seafood | Occur approximately 40 days after exposure; include
|
Self resolves without treatment |
| G; GB virus type C | Exposure to blood or semen of an infected person; on occasion from mother to neonate | HGV is often asymptomatic. In some cases, mild symptoms include fatigue abdominal discomfort mild jaundice GBV-C is typically asymptomatic; occasionally associated with mild hepatitis symptoms |
HGV has no specific antiviral treatment required as it generally does not cause chronic liver disease; management focuses on monitoring liver function and addressing any associated liver conditions. GBV-C has no specific antiviral treatment available; typically, management involves monitoring and supportive care, especially if there is coinfection with other hepatitis viruses. |
Link to Learning
Click here to learn about Recommendations for Testing, Managing, and Treating Hepatitis C developed by the American Association for the Study of Liver Disease and Infectious Diseases Society of America.
Pathophysiology
In chronic liver disease, inflammation occurs as a natural response to injury, but liver cells are not able to properly regenerate. An overproduction of collagen is created from the persistent inflammatory state, stiffening the area and causing scarring or fibrosis to occur. Without treatment, the fibrosis continues, replacing healthy cells and leading to cirrhosis, or severe scarring of the liver (Figure 19.21). It is most commonly caused by chronic alcohol use and hepatitis. The cirrhosis continues until there are no healthy liver cells left and the liver is no longer able to function, causing ESLD.
Acute liver disease progresses much more quickly and begins with inflammation, massive necrosis, and autonomous cellular dismantling of liver cells. The inflammation in the liver can trigger microglia activation in the brain, cause disruptions in the blood-brain barrier, and lead to astrocyte swelling and cerebral edema (Shah et al., 2023).
Causes of cirrhosis include
- alcohol-induced hepatitis from chronic heavy alcohol use
- autoimmune diseases, such as autoimmune hepatitis, primary biliary cholangitis, or primary sclerosing cholangitis
- cardiovascular disease, such as congestive heart failure
- chronic hepatitis B infection
- chronic hepatitis C infection
- genetic disorders, such as cystic fibrosis, glycogen storage disease, or Wilson disease
- nonalcohol-related steatohepatitis (fatty liver disease) from high lipids, diabetes, or hypertension
- toxic hepatitis from long exposure to environmental toxins or use of certain medications
Treatment for liver disease includes treating the underlying cause with antivirals, corticosteroids, immunosuppressants, and substance use disorder treatment; healthy diet and lifestyle; and treating complications appropriately, such as endoscopy for esophageal varices, paracentesis for ascites, and beta blockers for portal hypertension (Cleveland Clinic, 2023a).
Clinical Manifestations
Signs of chronic liver disease may be nonspecific and include anorexia, weight loss, fatigue, ascites, esophageal varices, or jaundice (Sharma & Nagalli, 2023). Signs of acute liver failure may include hypotension, altered mental status, fever, jaundice, right upper quadrant pain, ascites, jaundice, or fluid overload (Shah et al., 2023). Signs and symptoms of cirrhosis include
- ascites
- dark-colored urine
- decreased urine output
- digestive problems
- edema
- hepatic encephalopathy
- jaundice
- light-colored stools
- motor dysfunction
- pruritus
- shortness of breath
- unexplained weight loss
Assessment and Diagnostics
A physical assessment may reveal a change in mental status, jaundice, ascites, peripheral edema, gynecomastia (enlarged breast tissue in male patients), testicular hypertrophy (enlarged testis), or testicular atrophy (testes reduced in size), muscle wasting, signs of GI bleeding, pruritus, encephalopathy, and right upper quadrant pain.
Liver function tests may show increased alanine transaminase (ALT) level and aspartate aminotransferase (AST) levels, bilirubin and prothrombin times will be increased, and albumin level decreased. Blood ammonia levels may be elevated, indicating hepatic encephalopathy (Table 19.10).
| Category | Description |
|---|---|
| Symptoms |
|
| Diagnosis |
|
| Treatment | Identify and treat the underlying cause. Treatment may include
|
Abdominal ultrasound can diagnose cirrhosis, portal hypertension, or thrombus. A CT or MRI scan will help the radiologist evaluate the shape and size of the liver and measure its fibrosis or elasticity (Cleveland Clinic, 2023a). A liver biopsy can confirm chronic liver disease. A toxicology screen, acetaminophen level, and serologies for viral hepatitis, HIV, and autoimmune markers may be ordered to determine causes.
Nursing Care of the Patient with Liver Disease
Nursing care of the patient with liver disease focuses on supporting body systems, reducing risk of injury, monitoring and managing complications, improving nutritional status, providing skin care, and education. The patient’s mental status may range from alert to lethargic. The head of the bed should remain elevated. This helps facilitate venous drainage from the head (because of gravity), reducing intracranial pressure. Elevating the head of bed also helps with aspiration prevention during meals. Ensure the patient’s skin is kept clean and dry and apply lotion to prevent itch. Educate the patient and family about the importance of maintaining a healthy diet.
Recognizing Cues and Analyzing Cues
The nurse caring for a patient in acute liver failure needs to be alert for cues. Any change could indicate a worsening in condition. Cues could include a decline in mental status, bleeding from an old venipuncture sites and orifices, or a reduction in urine output.
Prioritizing Hypotheses, Generating Solutions, and Taking Action
A mental status decline accompanying an increase in ammonia level may indicate hepatic encephalopathy. The bleeding at a venipuncture site followed by oozing of blood from every site or orifice available could indicate coagulopathy, such as disseminated intravascular coagulation. A drop in urine output could indicate that kidney function is compromised.
Evaluation of Nursing Care and Outcomes for the Patient with Liver Disease
The evaluation of nursing care will explore all aspects of care. The first evaluation will be to determine if the goal was met. Goals may include (1) The patient will maintain urine output of at least 30 mL/hour by end of shift; and (2) the patient will experience no signs or symptoms of infection. Other goals may be written that are patient specific.
The primary patient outcome related to liver disease management is to preserve health and reduce complications. Subjective data reported by the patient can inform the nurse if symptoms of dyspnea and pain have improved. Reviewing trends of vital signs, weight, and abdominal girth measurements can provide objective data about improvements in fluid retention. Comparing other data, such as laboratory values, can indicate trends reflecting the patient’s liver function, effectiveness of medications, and nutritional status.
Medical Therapies and Related Care
Treatment of liver disease is interdisciplinary and involves stopping progression of disease and preventing complications. Although cirrhosis is not curable, treatment of the underlying cause can slow or prevent the progression to liver failure.
Common complications seen with chronic liver disease are esophageal varices, hepatic encephalopathy, hepatorenal syndrome (kidney dysfunction in patients with advanced liver disease), and hepatocellular carcinoma. Complications of acute liver disease can include sepsis, cerebral edema, multiorgan failure, and death.
Other specific treatments include viral suppression for viral hepatitis; alcohol abstinence; treatment of metabolic syndromes; identification and cessation of use of drugs or toxins; and immunosuppression and prescription of corticosteroids for autoimmune disorders. Once a patient has reached ESLD, organ transplantation is the final option for treatment.
ESLD and Liver Transplantation
Liver transplantation is the proven treatment for patients with ESLD. The healthy liver may be a whole liver from a deceased organ donor or a partial liver from a living donor (Figure 19.22). A partial liver can regenerate to full size within a few months. The Model of End-Stage Liver Disease (MELD) Score is used to predict survival of patients with cirrhosis and is a tool used to prioritize organ allocation for liver transplantation.
Indications
The indication for liver transplantation is ESLD. It can be caused by conditions such as:
- acute liver failure
- alcohol-related liver disease
- autoimmune hepatitis
- chronic hepatitis C
- hepatitis B
- hepatocellular carcinoma
- nonalcoholic steatohepatitis
- primary biliary cirrhosis
- primary sclerosing cholangitis
- Wilson disease
Contraindications to liver transplantation include a MELD score less than 15, advanced cardiac or pulmonary disease, acquired immunodeficiency syndrome, active substance and/or alcohol use disorder, metastatic cancer, lack of psychosocial support, severe psychologic disease, and untreated shock or sepsis.
Immunosuppression
The goals of immunosuppression are to reduce the risk of graft rejection and minimize recurrent disease and adverse effects. Although most drug regimens are transplant-center specific, most programs use a glucocorticoid (prednisone), a calcineurin inhibitor (tacrolimus), and an antimetabolite (mycophenolate) (Vierling & Brandman, 2023). Immunosuppression medications must be taken for life, and the patient must be educated on the importance of not missing a dose and ensuring they do not run out of medication. A complication of immunosuppression is increased susceptibility to infection. Provide patient education about proper hand hygiene and avoiding large crowds.
Ethical Considerations
Alcohol-related liver disease is the leading cause for liver transplantation in the United States. There is controversy regarding the ethical issues that arise from determining which patients with a history of alcohol or drug use disorders can receive organs, especially in patients with less than 6 months of sobriety. Patients who are determined to be a high risk for future drug or alcohol use are often not considered for transplantation. Patients with poor social support systems, recent mental health crisis, and a history of medical noncompliance can also be contraindicated for transplant.
Black people and women have lower rates of referral to transplant centers, and patients with public insurance have worse post-transplant outcomes than patients with private insurance (Wahid et al., 2020). Locations of transplant centers also tend to be in predominantly White neighborhoods, causing non-White patients to have to travel farther for care.
Care of the Patient Receiving a Liver Transplant
On the inpatient side, the patient will be admitted to the ICU and will have vital signs recorded a minimum of every hour, as well as intake and output data. Any parameter that falls outside the desired will be referred to the critical care provider. This will occur for 2 to 3 days. Then, the patient will be transferred to a medical-surgical unit. The patient will have a routine postoperative experience: tolerating foods, ambulation, incentive spirometry, splinting, and lots of education on liver transplant care. The patient must know when to call the provider, signs and symptoms of an infection, organ rejection, lymph node enlargement, and skin changes. All routine cancer screenings should be completed in a timely manner.
Food and nutrition are important, and the patient should strive to eat healthy, balanced meals. Alcohol should be avoided. Consumption of water from lakes or rivers, unpasteurized milk, and raw or undercooked eggs, meats, and seafood may increase risk of infection. In addition, the patient should limit their intake of salt, cholesterol, fat, and sugar.
Disorders of the Gallbladder
The gallbladder stores and concentrates bile from the liver. The bile is then released into the duodenum, where it helps the body break down and absorb fats from food. Inflammation of the gallbladder is cholecystitis. A gallbladder stone is called a cholelithiasis. It is made from substances in the gallbladder and is benign unless it moves and blocks the common bile duct, a condition called choledocholithiasis, in which case, urgent surgery is required (Figure 19.23).
Women of all ages are more likely than men to have gallbladder disease and gallstones, possibly due to estrogen levels. Age and family history also are risk factors. American Indians have genes that affect cholesterol in bile, resulting in the highest rate of gallstones in the United States. Additionally, Mexican Americans are also at a significant risk of developing gallstones. Individuals with metabolic syndrome, diabetes with insulin resistance, and fast weight loss are all at elevated risk.
Pathophysiology
Gallstones can be formed by cholesterol or bilirubin and can range in size. Stones may temporarily block the cystic duct or pass into the common bile duct, creating temporary symptoms called biliary colic (Steel, 2022). Occlusion of the cystic duct for an extended period can cause acute cholecystitis. Occlusion of the common bile duct causes choledocholithiasis. This can lead to infection and inflammation of the bile duct system.
Clinical Manifestations
Gallstones are often asymptomatic and do not produce symptoms unless they block the common bile duct. Symptoms can include sudden severe pain in the right upper abdomen, nausea, and vomiting. Symptoms of cholecystitis include
- abdominal bloating
- chills
- dark urine
- fever
- jaundice
- nausea, vomiting
- severe, sudden right upper quadrant pain that becomes sharp when palpated
- sharp pain when breathing in
Assessment and Diagnostics
The nurse will complete a focused subjective history and physical assessment. The patient may present with classic reports of severe right upper quadrant pain, nausea and vomiting. A physical assessment may reveal jaundice, abdominal bloating, and stiff abdominal muscles.
Although laboratory values may be normal in cases of cholelithiasis, the patient’s WBC count may be elevated. AST, ALT, and alkaline phosphatase levels may also be elevated, which increase the patient’s risk for bleeding. Blood cultures may be completed if the patient is febrile. Other bloodwork may be completed to rule out other conditions, such as pancreatitis. An ultrasound is the most common diagnostic imaging procedure performed to diagnose both cholecystitis and cholelithiasis. Other diagnostic imaging, such as a CT scan or hepatic 2,6-dimethyliminodiacetic acid (HIDA) scan, may be completed.
Nursing Care of the Patient with Gallbladder Disorders
Patients with gallbladder disorders are at risk for fluid volume deficit and imbalanced nutrition. Nursing care to prevent these risks include
- accurate monitoring of intake and output
- administering pain medications as ordered
- assessing for abnormal bleeding
- encouraging food intake
- monitoring for increased or continued nausea and vomiting
- providing patient education about the disease, treatment, and prevention
Recognizing Cues and Analyzing Cues
Using both subjective and objective data will help optimize care. Subjective data can include the patient’s report of pain, nausea, and vomiting. Vital signs may show hypotension from fluid loss and fever caused by infection. Jaundice would indicate that the common bile duct is blocked and surgery may be required. The nurse educates the patient about treatment, assists with diagnostic testing, and prepares the patient for surgery.
Prioritizing Hypotheses, Generating Solutions, and Taking Action
Patients with gallbladder disorders are at risk for imbalanced nutrition. Interventions the nurse can do to promote adequate nutrition include administering prescribed antiemetic medications, collaborating with the nutritionist to provide foods the patient prefers, encourage ambulation to promote peristalsis, and providing nutritional supplements as ordered.
Evaluation of Nursing Care and Outcomes for the Patient with Gallbladder Disorders
In evaluating the nursing care provided, the nurse examines the goals created and evaluates if they were met. Interventions may be adjusted as needed during care to reach goals. A primary goal for patients with gallbladder disorder is pain relief. The nurse asks the patient about their pain level and if it has improved. The nurse can also look at objective data, such as pain medication use trends. If the patient is not getting adequate pain relief but is not requesting pain medications, the nurse knows that re-education may be needed about pain medication use and the healing process.
Medical Therapies and Related Care
Initially, patients will be NPO and receiving IV fluid therapy to rest the gallbladder and decrease inflammation. Surgery is the recommended treatment for cholecystitis, to either remove the gallstone causing the inflammation or to remove the gallbladder. Surgery can be emergent or scheduled, depending on the severity of symptoms. IV antibiotic therapy is also prescribed in the presence of infection. Pain medications may also be prescribed to control pain. Education about diet encourages patients to avoid foods that can increase recurrence of disease, such as fried foods, fast foods, sugary foods, foods high in saturated fat, cruciferous vegetables, and pectin.
Disorders of the Pancreas
The pancreas has two main functions in the body. It produces insulin to regulate blood sugar levels and produces enzymes to aid in food digestion. When the pancreas cannot function to produce digestive enzymes, malnutrition can occur. This section explores pancreatitis and pancreatic cancer.
Pancreatitis
Inflammation of the pancreas, pancreatitis, is the leading cause of GI hospitalizations in the United States (Gapp et al., 2023). Pancreatitis can be acute or chronic. Hospitalization rates for acute pancreatitis are three times higher among Black people than White people (Tang, 2021). Common risk factors to developing pancreatitis include alcohol use disorder, recent history of operative or invasive procedures, a family history of hypertriglyceridemia and gallstones.
Pathophysiology
Pancreatitis is caused by an inflammatory response to a duct obstruction, pH imbalance, or problems with calcium homeostasis (Tang, 2021). These may prevent bile from being released to aid in food digestion. Inflammation of the pancreatic tissues eventually leads to tissue damage. If it continues to progress, the pancreas could become necrotic and cause multiorgan dysfunction syndrome.
Clinical Manifestations
Patients may present with severe abdominal pain that may radiate to the chest or back, accompanied by nausea, vomiting, tachycardia, fever, hypotension, and jaundice. Pain may become worse after eating fatty foods. Three assessment signs associated with bleeding in pancreatitis are the Cullen’s sign, Grey-Turner’s sign, and Fox’s sign (Table 19.11 and Figure 19.24).
| Assessment | Characterization |
|---|---|
| Cullen’s sign | Ecchymosis over the periumbilical area; indicates peritoneal hemorrhage |
| Grey-Turner’s sign | Flank ecchymosis; indicates retroperitoneal hemorrhage |
| Fox’s sign | Bruising over the inguinal ligament (upper outer thigh); indicates retroperitoneal bleeding |
Assessment and Diagnostics
Patients with pancreatitis may present with nonspecific symptoms, such as nausea, vomiting, abdominal pain, tachycardia, and fever. The nature of the pain may vary, depending on the cause of the pancreatitis. Initial bloodwork would be completed to narrow down a cause of symptoms. Pancreatitis will result in an elevated lipase or amylase level. Elevation of liver enzyme levels (e.g., AST, ALT, total bilirubin) may indicate gallstones as the cause of pancreatitis. Calcium, triglyceride, and cholesterol levels will be evaluated depending on the cause of pancreatitis. Glucose levels may be elevated secondary to beta-cell injury in the pancreas. An elevated WBC count may indicate infection. Arterial blood gas samples may be obtained if the patient is experiencing dyspnea. Abdominal ultrasound can detect gallstones. Endoscopic ultrasonography can visualize the pancreas and biliary tract.
Prioritizing Hypotheses, Generating Solutions, and Taking Action
The patient with acute pancreatitis will need aggressive fluid resuscitation, pain management, and strict intake and output monitoring. Blood glucose levels will also be monitored. The patient will need frequent assessments of respiratory status and fluid and electrolytes status. Patient education will be provided on an ongoing basis.
Analysis of subjective and objective data will allow the nurse to provide optimal care. Although subjective data may be nonspecific and include abdominal pain, nausea, and vomiting, objective physical assessment data may reveal jaundice, a positive Cullen’s sign, and abdominal rigidity. These would cue the nurse to suspect pancreatitis.
The nurse recognizes that fluid resuscitation is a priority for the first 24 hours. Vital signs should be monitored for signs of overhydration, such as hypertension. Strict intake and output monitoring can allow the nurse to monitor fluid balance.
Evaluation of Nursing Care and Outcomes for the Patient with Pancreatitis
The evaluation of nursing care will include determining if the patient’s condition has improved and if goals have been met. Examples of goals are:
- The patient will state pain is reduced to [insert number between 0 and 10].
- The patient will state what causes pancreatitis.
- The patient will verbalize a commitment to follow-up care.
These goals are evaluated, care is adjusted, and the patient continues to receive care unless the health issue does not require the nurse to follow-up. The nurse must evaluate each intervention and the outcome. To evaluate the effectiveness of pain management, the nurse evaluates subjective data provided by the patient, such as ability to rest comfortably with pain at a tolerable level.
Medical Therapies and Related Care
For acute pancreatitis, medical management includes fluid resuscitation and nutritional support. Antibiotics may be ordered if the cause is suspected to be infection. Surgical intervention is indicated in the presence of gallstones, duct disruption, infective pancreatic necrosis, or abscess. If the patient cannot maintain nutritional needs, parenteral nutrition may be initiated.
For chronic pancreatitis, treatment goals include decreased abdominal pain and increased nutrition absorption. Nonopioid pain regimens may be used, and pancreatic enzymes will be prescribed to aid in food absorption. The provider will order a high-protein, high-calorie diet. The dietitian will assist the patient with meal planning as needed. Interventional radiology procedures or surgical resection of the pancreas may be required in certain cases, depending upon the patient’s general health condition, previous procedures, and symptoms.
Pancreatic Cancer
Pancreatic cancer typically grows in the head of the pancreas and accounts for 3 percent of all cancer in the United States (Cancer.net, 2023). It is more common in men than women. Black men have a higher incidence of pancreatic cancer than other racial groups. Risk factors are cigarette smoking, diabetes, obesity, chronic pancreatitis, cirrhosis of the liver, H. pylori infection, work exposure to chemicals, and family history. The most common type of pancreatic cancer is pancreatic ductal adenocarcinoma. It may spread to the liver, lung, or more distant sites. The 5-year survival rate is 12.5% (Cancer.net, 2023).
Pathophysiology
The pathophysiology of pancreatic cancer is a growth, typically adenocarcinoma, of abnormal cells. The immune system does not stop the growth of the tumor.
Clinical Manifestations
Pancreatic cancer is rarely found at an early stage, because it lacks clinical manifestations until disease has advanced. Common signs and symptoms include abdominal pain, unexplained weight loss, jaundice, itching, dark urine, light-colored stools, fatigue, or history of recurring deep vein thrombosis from hypercoagulability. Patients may also have a new diagnosis of diabetes or diabetes that is harder to control than normal.
Assessment, Diagnostics, and Laboratory Values
Physical assessment may reveal the presence of a palpable mass. Clinical manifestations and assessment findings will prompt the provider to suspect cancer. Initial laboratory findings will show elevated liver function tests and elevated levels of direct and total bilirubin, lipase, amylase, and pancreatic tumor markers.
Multidetector CT is the preferred imaging modality to evaluate the extent of disease. PET scanning can detect distant metastatic disease. ERCP with endoscopic ultrasound may be performed and suspicious tissues may be biopsied.
Nursing Care of the Patient with Pancreatic Cancer
The care of the patient with pancreatic cancer will start with teaching the patient about the biopsy process. When the results are available and the provider has given the patient the diagnosis, the nurse can provide education and emotional care. Nursing care may be to support patient’s decisions on surgery, radiation, or chemotherapy. This can also progress to coordinating palliative or hospice care.
As part of nursing care, the nurse will recognize and analyze cues. The nurse will complete the history and the physical assessment. Of all the symptoms of pancreatic cancer, a significant cue is the ability to palpate an abdominal mass. The nurse will then prioritize hypotheses, generate solutions, and take action. The nurse makes the hypothesis that the problem is a pancreatic tumor. Immediate reporting is completed, and the nurse starts addressing prescriptions as they are ordered.
Evaluation of Nursing Care and Outcomes for the Patient with Pancreatic Cancer
Nursing care must be evaluated. Two examples of goals that need to be evaluated are (1) the patient will verbalize all the details for having a biopsy completed, and (2) the patient will state how to care for skin while jaundice is present.
In caring for a patient with pancreatic cancer, the outcomes may be different than those discussed in this chapter. Certainly, the patient should understand the diagnosis and the treatment options. Ultimately, the goal is for the patient to reach a place of acceptance regarding the terminal nature of their diagnosis. Success in this context is not about finding a cure but rather providing compassionate care and support throughout their journey.
Medical Therapies and Related Care
Medical treatment depends on location and advancement of disease. Surgery is an option in only 20% of pancreatic cancer cases (Cancer.net, 2023). The surgical procedure often performed is a Whipple procedure (Figure 19.25), or a pylorus-preserving Whipple procedure. The head of the pancreas, the bile duct, gallbladder, and duodenum are removed. The pancreas may even be removed, and the patient may need to take insulin.
Supportive surgery and palliative procedures are often recommended to help with symptoms affecting a patient’s quality of life. Examples of palliative procedures and surgery can include bypass surgery, stent placements, and nerve blocks to alleviate jaundice, nausea and vomiting, and tumor-associated pain.
Other therapies, such as chemotherapy and/or radiation, targeted therapies, and immunotherapy, may also be performed alone or in conjunction with other treatments. Psychological and clerical support are also an important aspect of treatment.