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Chapter 35 Nursing Care of Patients With Liver, Pancreatic, and Gallbladder Disorders
Risk for Deficient Fluid Volume
EXPECTED OUTCOME: The patient will have adequate fluid
volume as evidenced by stable vital signs, elastic skin
turgor, and moist mucous membranes.
• Monitor the patient’s intake and output carefully. Low
intake increases risk of deficient fluid volume; low output
is a sign of deficient fluid.
• Monitor vital signs. Tachycardia, tachypnea, and low
blood pressure may indicate excessive fluid loss.
• Monitor laboratory values, especially serum sodium,
potassium, calcium, and chloride levels. Report abnormal
values. If electrolyte values are low, the physician may
order IV replacement solutions.
• Report low serum albumin level (normal is 3.4–4.8 g/dL)
and assist with monitoring IV albumin therapy if ordered.
Low albumin places the patient at risk for fluid
imbalances.
• Carefully observe the patient for signs of blood loss that
may indicate abnormal bleeding:
• Bruising, bleeding gums, or pink-tinged urine
• Cullen’s sign (bluish discolorations around the
umbilicus)
• Turner’s sign (bluish discolorations on the flanks)
• Bleeding at incision and drain sites and in drainage
tubing
• Teach the patient to use a soft-bristle toothbrush and
electric razor rather than a straight razor to reduce risk
of injury and bleeding.
• Administer vitamin K as ordered to replace deficiency
and to reduce risk for bleeding.
Risk for Impaired Tissue Integrity related to itching and to
leaking around drainage tubes
EXPECTED OUTCOME: The patient’s skin will remain intact.
• Monitor the patient for reports of itching because scratch-
ing can cause a break in the skin.
• Help the patient keep fingernails short to reduce damage
to skin with scratching.
• Provide frequent skin care with products free of soap or
alcohol to prevent further dryness and itching.
• Protect skin around drains with skin-protective barrier
products and ostomy bags to prevent skin damage.
• Apply products such as calamine lotion as ordered to de-
crease itching.
• Exercise special care of any drains to prevent unnecessary
tension that may cause sutures to give way.
• Keep all drains patent, and keep drainage tubing and
bags free from kinks to prevent fluid leakage onto
the skin.
• Place the patient in semi-Fowler’s position to help with
gravity drainage and reduce risk of fluid leakage.
EVALUATION. The plan of care for the patient with pancreatic
cancer is successful if the patient maintains body weight within
5% of normal body weight and e xperiences no nausea or
vomiting; states that pain remains tolerable at 2 or less on a
pain scale of 0 to 10; has urinary output greater than 30 mL/hr,
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elastic skin turgor, moist mucous membranes, pulse and blood
pressure within 10% of patient’s baseline, no sudden, excessive
abdominal pain or rigidity, and incisions heal at the e xpected
rate; demonstrates the appropriate self-care procedures for
tubes, drains, dressings, and medication administration; and
states the signs and symptoms of complications that are to be
reported immediately.
PATIENT EDUCATION. Teach the patient and f amily self-
care measures such as blood glucose monitoring, insulin
administration, signs and symptoms of hyper glycemia
and hypoglycemia (see Chapter 40), and the re gimen for
pancreatic enzyme replacement. Instruct the patient on how
to manage dressing changes if he or she is to be discharged
with tubes or drains. P atient and family should know the
signs and symptoms of hemorrhage, gastric ulceration,
infection, and fistula formation. A patient being cared for
at home should ha ve a referral for hospice care or home
nursing care.
For more information, visit the National P ancreas Foun-
dation at www.pancreasfoundation.org.
DISORDERS OF THE GALLBLADDER
Cholecystitis, Cholelithiasis,
and Choledocholithiasis
Gallstones and inflammations of the gallbladder and common
bile duct are the most common disorders of the biliary
system.
Pathophysiology
Cholecystitis is an acute or chronic inflammation of the
gallbladder. It is most often a response to obstruction of the
common bile duct resulting in edema and inflammation.
Bacteria can invade stagnant bile and add to the inflamma-
tion and irritation of the gallbladder. Chronic cholecystitis
may be the result of repeated attacks of acute cholec ystitis
or chronic irritation from gallstones. The gallbladder then
becomes fibrotic and thickened and does not empty easily
or completely. This is a risk factor for gallbladder cancer.
Cholelithiasis is the formation of gallstones in the gall-
bladder that are most often composed of cholesterol in the
United States. They can be asymptomatic for decades. Chole-
docholithiasis refers to gallstones within the common bile
duct. Gallstones form when bile becomes supersaturated with
a substance such as cholesterol, which then crystallizes, form-
ing sludge with continued enlar gement to form stones. An-
other type of gallstone is a pigment stone. Pigment stones are
composed of calcium bilirubinate, which occurs when free
bilirubin combines with calcium.
• WORD • BUILDING •
cholecystitis: chole—bile + cyst—bladder + itis—inflammation
cholelithiasis: chole—bile + lith—stone + iasis—condition
choledocholithiasis: chole—bile + docho—duct + lith—stone +
iasis—condition