Bothaina Hassan, PhD, RN

Sheeba Kumari, MSN, RN, RM

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 Syllabus
• Nursing care and management of the patient with
hepatic and pancreatic disorders
• Portal hypertension, ascites, hepatic encephalopathy
• Esophageal varices
• Hepatitis A, B, C
• Liver failure
• Gallbladder disease
• Cholecystitis
• Cholelithiasis
• Acute pancreatitis
• Pancreatic cysts

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 OBJECTIVES
– At the end of the class students will be able to :
– Describe the structures and functions of Hepatobiliary
and pancreas
• Explain Portal hypertension, ascites, hepatic
encephalopathy, and Esophageal varices
• Discuss Hepatitis A, B, and C
• Discuss Liver failure
• Explain Gallbladder disease
• Discuss Acute pancreatitis and Pancreatic cysts
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 Diagnostic/Laboratory Tests
1. CA-19-9
A tumor antigen found in serum; used as a marker for pancreatic
cancer.
Nursing and Patient Care Considerations
-Tell patient a blood test will be taken and the results will be ready in 1
to 3 days.
2. Alpha-fetoprotein
-An oncofetal antigen found in serum. Alpha-fetoprotein (AFP) is
elevated in 70% to 95% of hepatocellular carcinomas (primary liver
cancer).
Nursing and Patient Care Considerations
-Tell patient a blood test will be taken and the results will be ready in 1
to 3 days.
-AFP may also be elevated in certain tumors of the gonads (testes and
ovaries), retroperitoneum, and mediastinum. 6
3. Ultrasonography
-A noninvasive test focuses high-frequency sound waves over an area in
the abdomen to generate an image of the structure.
- Ultrasound of the abdomen can detect gallstones, dilated bile ducts,
fluid-filled cysts, ascites, and small abdominal masses
-It is reported to be able to detect gallstones with 95% accuracy

4. Hepatobiliary Scan
-A noninvasive nuclear study using radioactive materials to evaluate
gallbladder function and aid in the diagnoses of hepatobiliary
disorders.
A radioactive agent is administered I.V. It is taken up by the hepatocytes
and excreted rapidly through the biliary tract.
Nursing and Patient Care Considerations
- Nothing by mouth (NPO) for at least 4 hours before the procedure.
- If possible, no opiates should be administered for at least 6 hours
before the procedure

Post procedure: Increase fluid intake

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 Diagnostic/Laboratory Tests..
5. Endoscopic Retrograde Cholangiopancreatography (ERCP)
- (ERCP) involves visualization of the common bile, pancreatic, and
hepatic ducts with a flexible fiber-optic endoscope inserted into the
esophagus, passed through the stomach and into the duodenum.
Nursing and Patient Care Considerations :Pre procedure
- Assess for allergies to iodine, seafood, or contrast media to determine
the need for premedication with antihistamines or steroids (per facility
protocol) to prevent a reaction.
- NPO for at least 6 hours before the procedure. heparin should have
the infusion off for 4 to 6 hours before the procedure
Post procedure: -Monitor and document vital signs.
-Observe for and report abdominal distention and signs of perforation, GI
bleeding or possible pancreatitis, including chills, fever, pain,
vomiting, hypotension, tachycardia. Notify health care provider
immediately.
8
-Maintain NPO status until gag reflex returns.-
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 Diagnostic/Laboratory Tests…
6. Endoscopic Ultrasound
-In endoscopic ultrasound (EUS), a high-frequency ultrasound
probe is placed at the tip of an endoscope to assess the
pancreas through the GI lumen.
-This helps to provide images of the pancreas and adjacent
organs.
Nursing and Patient Care Considerations Pre -procedure
-The same as for ERCP.
- Instruct patient that tissue may be obtained for analysis.
- Verify that patient has a signed informed consent for the
procedure and tissue aspiration before sedation is given.
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7. Magnetic Resonance Cholangiopancreatography
(MRCP)
can detect the level and presence of biliary obstruction,
but cannot offer therapeutic intervention
Nursing and Patient Care Considerations Pre procedure
- Confirm that patient does not have a pacemaker
because the magnetic field could cause pacer
malfunction.
- Confirm that patient does not have any metal
hardware in or on the body, such as internal
defibrillator, surgically placed inner ear devices, metal
joint replacements.
- Post procedure: Patient may resume usual activities.
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8. Liver Biopsy
- Sampling of liver tissue through needle aspiration to establish a
diagnosis of liver disease through histologic study.
Nursing and Patient Care Considerations Pre procedure
-Establish baseline hemoglobin level, hematocrit, and platelet count.
-Make sure PT is within normal limits.
-Verify informed consent.
Post procedure
-Position patient on right side with pillow supporting lower rib cage
for several hours.
-Check vital signs and observe biopsy site frequently for bleeding or
drainage
- Report increasing pulse, decreasing blood pressure (BP), increasing
pain, and apprehension, which may indicate hemorrhage.

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9. Fine-Needle Aspiration (FNAC)
1. The removal of fluid from a cyst or the removal of cells from a mass
to establish a diagnosis through histologic study.
2. A fine needle is inserted into the suspicious area and a small sample is
withdrawn.
3. The needle is guided by fluoroscopy, CT scan, or ultrasound and can
usually reach most internal organs with minimal risk to the patient.
Nursing and Patient Care Considerations Pre procedure
1. Establish baseline hemoglobin, hematocrit, and platelet count.
2. Verify informed consent.
3. Establish baseline vital signs.
4. Tell patient that a mild sedative may be given and a pain block may
be performed in the area where the needle will be placed.
5. An I.V. may be inserted for sedation as needed
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Post procedure
1. Monitor vital signs per facility protocol.
2. Assess patient for any signs of complications, including
pain, hypotension, tachycardia, and abdominal distention
or hematoma at the biopsy site.
3. Inform patient that bruising or some discomfort may be
experienced at the biopsy site.
4. Instruct patient on resuming anticoagulants based on
health care provider directions.

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 Hepatitis
- widespread inflammation of the liver tissue w/ liver
damage due to hepatic cell degeneration & necrosis
- Proliferation & enlargement of the kupffer cells;
inflammation of the periportal areas (may cause
interruption of bile flow)
Hepatitis A
ØIs caused by a Ribonucleic acid virus of the enterovirus
family
ØMode of transmission is fecal-oral route. Usually
through the ingestion of food or liquids contaminated
w/ the virus
Ø prevalent in underdeveloped countries, overcrowded
and poor sanitation
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ØInfected food handler can spread the disease
Ø person to person contact rarely by blood transfusion
ØIncubation period 3 to 5 weeks
Hepatitis B (Serum Hepatitis)
ØIs a double shelled particle containing
deoxyribonucleic acid (DNA)
ØIncubation period 2 to 5 months
Ø Mode of transmission is primarily through blood
(percutaneous & permucosal route)
a. Oral route: through saliva, breastfeeding
b. Sexual activity: through blood, semen, saliva, or
vaginal secretions. Recognized as sexually
transmitted disease.
c. Blood and blood product: contaminated needles
from IV drug users 18
Hepatitis B

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Hepatitis C
>An RNA virus
ØMode of transmission in most cases is through
blood or blood products
ØFound among drug users and renal dialysis patients
ØCan be transmitted through sexual intercourse &
from mother to fetus
ØTransmitted through contaminated piercing,
tattooing tools & ink
Ø incubation period varies from 1 week to several
months
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Hepatitis D
Ø A defective RNA agent that appears to replicate only w/ the
hepatitis B virus. It requires HBsAg to replicate
Ø Occurs along w/ HBV or may superinfect a chronic HBV
carrier
Ø Mode of transmission and incubation are the same as for
HBV

Hepatis E
Ø A recently identified non-enveloped single strand RNA virus
Ø Mode of transmission is fecal-oral route but because this
virus is inconsistently shed in feces detection is difficult
Ø Incubation is the same as for HAV 22
ASSESSMENT FINDING FOR HEPATITIS A
Preicteric stage:
a. Anorexia, nausea and vomiting, fatigue, constipation or diarrhea,
weight loss
b. Right upper quadrant discomfort, hepatomegaly, splenomegaly,
lymphadenopathy
c. Highly contagious usually 2 weeks before the onset of jaundice
Icteric stage:
a. Fatigue, weight loss, clay coloured/light colored stools, dark urine
(The liver is unable to excrete bilirubin.)
b. Continued hepatomegaly with tenderness, lymphadenopathy,
splenomegaly
c. Jaundice, pruritus
Posticteric stage:
a. Fatigue but an increase sense of well-being
b. Hepatomegaly gradually decreasing
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Hepatitis B
-Onset of symptoms usually more insidious and prolonged
compared w/ HAV
-Jaundice in icteric phase
-May progress to fulminant hepatic failure
-May be asymptomatic.
-One week to 2 months of prodromal symptoms: fatigue,
anorexia, transient fever, abdominal discomfort, nausea and
vomiting, headache.
-Extrahepatic manifestations may include myalgias,
photophobia, arthritis, angioedema, urticaria,
maculopapular eruptions, skin rashes, vasculitis.
- In rare cases, it may progress to fulminant hepatic failure, also
called fulminant hepatitis.
-May become chronic active or chronic persistent
(asymptomatic) hepatitis.
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Hepatitis C
-Similar to those associated w/ HBV but usually less severe
-Symptoms usually occur 6 to 7 weeks after transfusion but may be
attributed to another viral infection and not diagnosed as hepatitis.
- Approximately 60% to 85% of people infected with HCV go on to
develop a chronic infection.
-(Complications of chronic HCV include cirrhosis, decompensated liver
disease, and hepatocellular carcinoma.)
- In patients with HCV, the estimated risk of developing hepatocellular
carcinoma after 20 years is 1% to 5%.
Hepatitis D
-Similar to HBV but more severe.
- With superinfection of chronic HBV carriers, causes
sudden worsening of condition and rapid
progression of cirrhosis.
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 DIAGNOSTIC TESTS
a. Hepatitis A, B, C
-Liver Function test: Alanine AminoTransferase (ALT), Aspartate
Aminotransferase (AST), Alkaline phosphatase, bilirubin, ESR: all
increased (preicteric)
-leukocytes, lymphocytes, neutrophils: all decreased (preciteric)
-Prolong PT
b. Hepatitis A
-Hepatitis A virus (HAV) in stool before onset of disease.
-Anti-HAV (IgG) appears soon after onset of jaundice; peaks in 1-2
months and persists indefinitely
-Anti HAV (IgM): positive in acute infection; lasts 4-6 weeks
c. Hepatitis B
-HBsAg (Hepatitis B surface antigen): positive, develops 4-12 weeks
after infection
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d. Hepatitis C
-initial screening test Enzyme-linked Immunabsorbent Assay
(ELISA) test
-If ELISA test is positive and ALT is normal then Recombinant
Immunoblot Assay (RIBA) done
e. Hepatitis D
-rise in hepatitis D virus antibodies (anti-HDV) titer
f. Hepatitis E
-testing usually done for symptomatic persons who have
traveled to high risks areas
-Hepatitis E antibodies (anti-HEV) present

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 Nursing Interventions
1. Promote adequate nutrition.
a. Administer antiemetics as ordered 30 minutes before meals to
decrease occurrence of nausea and vomiting
b. Provide small frequent meals of a high carbohydrates, moderate
to high protein, high vitamin and high calorie diet
2. Ensure rest/relaxation: plan schedule for rest and activity periods.
3. Monitor/relieve pruritus.: cut short finger nails
4. Institute isolation procedures as required; pay special attention to
good hand washing technique and good sanitation
5. In Hepatitis A administer serum globulin (SG).
Avoid cough syrup (alcohol) (OTC)
7. In Hepatitis B
a. Screen blood donors for HBsAg
b. Use disposable needles and syringes
c. Instruct client/others to avoid sexual intercourse while disease is
active
d. Standard Precautions. 29
e. Administer Hepatitis B immunoglobulin as ordered to
provide temporary passive immunity to exposed
individuals.
To produce active immunity, administer hepatitis B vaccine to
those individuals at high risk.
**Needle stick with soap and water and attempt stick bleed
Nursing Diagnoses All Types of Hepatitis
Ø Imbalanced Nutrition: Less Than Body Requirements
related to effects of liver dysfunction
Ø Deficient Fluid Volume related to nausea and vomiting
Ø Activity Intolerance related to anorexia and liver
dysfunction
Ø Deficient Knowledge related to transmission
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 Jaundice
- Refers to yellowish color of the skin and other tissues that
results from high levels of bilirubin in the blood.
- Also called as hyperbilirubinemia
- Impaired bile acid excretion
(so prutitus)

Classification of Jaundice:
1. Prehepatic Jaundice
-Results from excessive destruction of red blood cells and is
characteristic of hemolytic anemias or transfusion reactions.
-Liver function is normal but is unable to handle additional
bilirubin
-Increase hemolysis of red blood cells combined with the
immature liver leads to transient mild hyperbilirubinemia 31
2.Intrahepatic Jaundice
- Occurs in individuals with liver disease such as hepatitis or
cirrhosis
- It is related to impaired uptake of bilirubin from the blood
and decrease conjugation of bilirubin by the hepatocytes
3. Posthepatic Jaundice
- Cause by obstruction of bile flow into the gallbladder or
duodenum and subsequent backup of bile into the blood
• physiologic jaundice of newborn is common 2 to 3 days
after birth
• Increase hemolysis of red blood cells combined with the
immature liver leads to transient mild hyperbilirubinemia
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 Cirrhosis of the liver
ØIs a disorder in which there is progressive
destruction of liver tissue leading eventually to liver
failure
Ø is characterized by widespread fibrotic (scarred)
bands of connective tissue that change the liver’s
normal makeup. Inflammation caused by either
toxins or disease results in extensive degeneration
and destruction of hepatocytes (liver cells).
ØAs cirrhosis develops, the tissue becomes nodular.
These nodules can block bile ducts and normal
blood flow throughout the liver. Impairments in
blood and lymph flow result from compression
caused by excessive fibrous tissue. 33
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 Cirrhosis of the liver…..
Types:
a. laennec’s cirrhosis- associated w/ alcohol abuse and
malnutrition. Characterized by accumulation of fat in the
liver cells progressing to widespread scar formation
b. Post necrotic cirrhosis- results in severe inflammation w/
massive necrosis as a complication of viral hepatitis
c. Cardiac cirrhosis- occurs as a consequence of right sided
heart failure , manifested by hepatomegaly w/ some
fibrosis
d. Biliary cirrhosis- associated w/ biliary obstruction, usually
in the common bile duct. Results in chronic impairment of
bile excretion

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 c. Clinical Manifestations:
1. Fatigue, anorexia, nausea and vomiting, indigestion,
weight loss, flatulence, irregular bowel habits.
2. Early symptoms: Hepatomegaly (pain in right
quadrant).Late symptoms: hard nodular liver upon
palpation; atrophy of liver.
3. Esophageal varices, internal hemorrhoids, ascites,
splenomegaly, pancytopenia
4. Plasma albumin is reduced leading to edema and ascites
5. Anemia and poor nutrition lead to fatigue, weakness,
wasting and depression

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6. Changes in mood, alertness and mental ability
7. Decrease axillary and pubic hair in males and amenorrhea in
females
8. Jaundice of the skin, sclera, mucous membrane, pruritus
9. easy bruising, bleeding tendencies
10. spider angiomas, palmar erythema

Diagnostic Test:
1. SGOT (AST), SGPT (ALT), LDH, Alkaline phosphatase
increased
2. Serum bilirubin is increased
3. PT prolonged: clotting problem
4. Serum albumin decreased
5. Hgb and hematocrit decreased
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 Dilated blood vessels
Ascites

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Caput medusae

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 Nursing Interventions of Cirrhosis of the Liver
1. Provide sufficient rest and comfort.
a. Provide bed rest with bathroom privileges.
b. Provide fowlers position/ 60 degree
b. Encourage gradual, progressive, increasing activity with planned
rest periods.
c. Institute measures to relieve pruritus.:
-do not use soaps and detergents.
-Bath 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.
2. Promote nutritional intake.
a. Encourage small frequent feedings.
b. Promote high calorie, low to moderate protein, high
carbohydrate
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Low fat diet, with supplemental vitamin therapy (Vitamin A,B,C,D,K and folic
acid)
3. Prevent Infection
a. Prevent skin breakdown by frequent turning and skin care
b. Provide reverse isolation for client with severe leukopenia (do
handwashing)
c. Monitor WBC count
4. Monitor and prevent bleeding
5. Administer diuretics as ordered
6. Provide health teachings: and discharge planning concerning:
-avoidance of agents that may be hepatotoxic (sedative, opioid analgesics)
-how to assess for weight gain and increased abdominal girth
-avoidance of straining at stool vigorous blowing of nose, coughing to
decrease incidence of bleeding
Complications:
Ø Hyponatremia and water retention
Ø Bleeding esophageal varices
Ø Coagulopathies
Ø Hepatic encephalopathy
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 NURING DIAGNOSES OF LIVER
CIRRHOSIS
Ø Activity Intolerance related to fatigue, general debility,
and discomfort
Ø Imbalanced Nutrition: Less Than Body Requirements
related to anorexia and GI disturbances
Ø Impaired Skin Integrity related to edema, jaundice, and
compromised immunologic status
Ø Risk for Injury related to altered clotting mechanisms
Ø Disturbed Thought Processes related to deterioration of
liver function and increased serum ammonia level.////
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1. Surgery for portal Hypertension *(decompresses
esophageal varices to maintain portal perfusion

a. Ligation of esophageal and gastric veins

b. Portacaval shunt- end to side or side to side
anastomosis of the portal vein to inferior vena
cava
c. Splenorenal shunt -end to side or side to side
anastomosis of splenic vein to left renal vein
d. . Mesocaval shunt: end to side or use of a graft to
anastomose the inferior vena cava to the side of
the superior mesenteric vein.
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 Ascites
- Accumulation of free fluid in the abdominal cavity
- Most frequently caused by cirrhotic liver damage, which produces
hypoalbuminemia, increased portal venous pressure, hyperaldosteronism
- pressure from portal hypertension. The collection of plasma protein in the
peritoneal fluid reduces the amount of circulating plasma protein in the
blood.
- Clinical manifestations
Ø Anorexia, nausea and vomiting, fatigue, weakness, changes in mental
functioning
Ø Positive fluid wave and shifting dullness on percussion, flat or protruding
umbilicus, abdominal distension, prominent veins, abdominal pain
Ø Peripheral edema, shortness of breath
Ø Diagnostic tests:
a. Potassium and serum albumin decreased
b. PT prolonged
c. LDH, SGOT (AST), SGPT (ALT), BUN sodium increased

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Ascites 50
Medical Management
1. Diet: low salt diet
2. Diuretic therapy
Diuretics medications:
a. Thiazide diuretics (Chlorothiazide, metolazone)
b. Loop diuretics (Furosemide, Bumetanide, Ethacrynic acid)
c. Potassium-sparing (Amiloride, spironolactone(side effect-Hyperkalemia),
triamterene)
3. Surgery
a. Paracentesis- insertion of a needle into the peritoneal cavity through the
abdomen to remove abnormally large amount of peritoneal fluids.
-peritoneal fluids is assessed for cell count, specific gravity, protein and
microorganism .
-post procedure: check vital signs (check hypovolemic shock)
b. LeVeen shunt (peritoneal venous shunt)
-used in chronic unmanageable ascites
-permits continuous reinfusion of ascitic fluid back into the venous system
through a silicone catheter with a one way pressure sensitive valve.

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Abdominal paracentesis

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Nursing Interventions:
1. Monitor nutritional status/provide adequate
nutrition and modified diet.
a. Restrict sodium c. promote high calorie
foods/snacks
b. Restrict fluids
.2.Monitor and prevent increasing edema.
a. Inspect/palpate extremities d. Measure I & O
b. Monitor peripheral pulses e. administer
diuretics as ordered
c. Measure abdominal girth
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3. Monitor/promote skin integrity
a. Assess for redness, skin breakdown c. Reposition frequently
b. Apply lotion to stretch areas
4. Promote comfort: Place client in semi-fowler’s and reposition
frequently
5. Provide nursing care for client undergoing paracentesis.
a. Confirm that client signed a consent form.
b. Instruct the client to empty bladder before the procedure to
prevent inadvertent puncture of the bladder.
c. Inform client that local anesthesia will be given
d. Measure abdominal girth and weight before and after
procedure
e. Assess the insertion site for leakage

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 Hepatic encephalopathy
ØFrequent terminal complication in liver disease
ØDiseased liver is unable to convert ammonia to
urea. So that large quantities remain in the systemic
circulation and cross the blood/brain barrier,
producing neurologic toxic symptoms
ØCaused by
ücirrhosis
üGI hemorrhage
ühyperbilirubinemia
üuremia
üdehydration
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Clinical manifestations:
a. Early in the course of the disease: changes in
mental functioning, insomnia, slowed affect,
impaired judgment, slow slurred speech,
slight tremor, Babinski’s reflex
b. Progressive disease: asterixis, disorientation,
apraxia, tremors, fetor hepaticus (breath odor
of acetone)
c. Late in disease: coma, absent reflexes

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Diagnostic tests:
Ø Serum ammonia levels increased
Ø PT prolonged
Ø Hgb and hct decreased
Nursing interventions:
1. Conduct neurologic assessment and report deteriorations.
check hand writing
2. Restrict protein**(60 to 80 g/day.) in the diet, provide high
carbohydrate intake and vitamin K supplements
3. Administer enemas, intestinal antibiotics and lactulose as
ordered to reduced ammonia levels.( 2-3 times stool pass
4. Orient the time, person and place(neurological ass.)
5. Checck hand writing
6. Avoid administration of drugs detoxified in liver
7. Maintain client on bed rest to decrease metabolic demands
on liver 59
 Esophageal Varices
-dilation of the veins of the esophagus, caused by portal
hypertension from resistance to normal venous
drainage of the liver into the portal vein
-cause blood to be shunted to the esophagogastric veins
resulting in distension, hypertrophy and increased
fragility.
-caused by portal hypertension which maybe secondary
to cirrhosis of the liver, alcohol abuse, increased intra-
abdominal pressure.
-may lead to Bleeding esophageal varices (is a life-
threatening medical emergency). Severe blood loss
may occur, resulting in shock from hypovolemia.
- 60
 Esophageal Varices…

The bleeding may be either hematemesis (vomiting

blood) or melena (black, tarry stools).
Loss of consciousness may occur before any
observed bleeding. Variceal bleeding can occur
spontaneously with no precipitating factors.
However, any activity that increases abdominal
pressure may increase the likelihood of a variceal
bleed, including heavy lifting or vigorous physical
exercise

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Assessment findings/Clinical Manifestations:
1. Anorexia, anusea and vomiting, hematemesis,
fatigue, weakness
2. Splenomegaly, increased splenic dullness, ascites,
caput medusae, peripheral edema, bruits
Diagnostic Tests:
-PT prolonged
-hematest of vomitus positive
-serum albumin, RBC, Hgb and Hct decreased
-LDH, SGOT (AST), SGPT (ALT), BUN, increased

63
 Medical Management of Esophageal Varices
1. Iced normal saline lavage
2. Transfusion with fresh whole blood
3. Vitamin K therapy
4. Sengstaken Blakemore Tube: a Three-lumen tube used to
control bleeding by applying pressure on the cardiac portion of
the stomach and against bleeding esophageal varices. One
lumen serves as NG suction; a second lumen is used to inflate
the gastric balloon; the third lumen to inflate the esophageal
balloon.
Nursing Interventions:
1. Monitor and provide care for patients with
Sengstaken Blakemore tube
a. Facilitate placement of the tube
b. Prevent dislodgement of the tube by placing client in semi-
fowlers position, maintain traction by securing the tube to a
piece of sponge or foam rubber place on the nose
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c. Keep scissors at bedside at all times:
d. Monitor respiratory status; assess for signs of
respiratory distress. If it will occur deflate the
balloons and remove tubing immediately. Stay with
patient
e. Label each lumen to avoid confusion; maintain
prescribed amount of pressure on esophageal
balloon
f. Observe nares for skin breakdown. Provide mouth
and nasal care every 1 to 2 hours

65
5.Intra-arterial or IV vasopressin
6.Injection of sclerotherapy
7. Banding

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 Fulminant Liver Failure
is acute necrosis of the liver cells without preexisting liver
disease, resulting in the inability of the liver to perform its
many functions.
Pathophysiology and Etiology
1. Viral hepatitis is the most common cause.
2. Poisons, chemicals, and such drugs as acetaminophen
(Tylenol), tetracycline (Tetracyn), isoniazid (INH),
halogenated anesthetics, monoamine oxidase inhibitors,
valproate (Depakene), amiodarone (Cordarone), methyldopa
3. Ischemia and hypoxia because of hepatic vascular occlusion,
hypovolemic shock, acute circulatory failure, septic shock
4. Progression of hepatocellular injury and necrosis is rapid,
with development of hepatic encephalopathy within 8
weeks of onset of disease.
5. Mortality is high, 60% to 85%, despite intensive treatment
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Clinical Manifestations
1. Malaise, anorexia, nausea, vomiting, fatigue.
2. Jaundice, especially mucous membranes.
3. Urine is tea-colored and frothy when shaken.
4. Pruritus caused by bile salts deposited on skin.
5. Steatorrhea and diarrhea because of decreased fat absorption.
6. Peripheral edema as the fluid moves from the intravascular to the
interstitial spaces, secondary to hypoproteinemia.
7. Ascites from hypoproteinemia or portal hypertension.
8. Easy bruising, petechiae, overt bleeding because of clotting deficiency.
9. Altered LOC, ranging from irritability and confusion to stupor, somnolence,
and coma.
10. Change in deep tendon reflexes—initially hyperactive, become flaccid,
asterixis (tremor).
11. Fetor hepaticus - breath odor of acetone.
12. hepatic encephalopathy
13. Cerebral edema is commonly the cause of death because of brain stem
herniation or because of respiratory arrest.

68
Diagnostic Evaluation
1. Prolonged PT, decreased platelet count.
2. Elevated ammonia, amino acid, and mercaptan levels.
3. Hypoglycemia or hyperglycemia.
4. Dilutional hyponatremia or hypernatremia, hypokalemia,
hypocalcemia, and hypomagnesemia.
Medical Management
a. Oral or rectal administration of lactulose (Cephulac) to minimize
formation of ammonia and other nitrogenous by-products in the
bowel.
b. Rectal administration of neomycin (Myciguent) to suppress
urea-splitting enteric bacteria in the bowel and decrease
ammonia formation.
c. Low-molecular-weight dextran or albumin followed by a
potassium-sparing diuretic (spironolactone) to enhance fluid shift
from interstitial back to intravascular spaces.
d. Pancreatic enzymes, if diarrhea and steatorrhea are present, to
permit better tolerance of diet.
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e. Mannitol (Osmitrol) I.V. for management of cerebral
edema when indicated.
f. Cholestyramine (Questran) to promote fecal excretion
of bile salts to decrease itching.
g. Antacids and histamine-2 (H2) antagonists to reduce
the risk of bleeding from stress ulcers.
h. Restriction of dietary protein and sodium while
maintaining adequate caloric intake with diet or
hypertonic dextrose solutions.
i. Supplemental vitamins (A, B complex, C, and K) and
folate.
j. Infusion of fresh frozen plasma to maintain PT;
cryoprecipitate as needed.
k. Liver transplant 70
Nursing Diagnoses
Ø Deficient Fluid Volume related to hypoproteinemia,
peripheral edema, ascites
Ø Ineffective Breathing Pattern related to anemia and
decreased lung expansion from ascites
Ø Imbalanced Nutrition: Less Than Body Requirements
related to GI adverse effects and decreased absorption,
storage, and metabolism of nutrients
Ø Risk for Impaired Skin Integrity related to malnutrition,
deposition of bile salts, peripheral edema, decreased
activity
Ø Risk for Infection related to altered immune response
Ø Risk for Injury related to encephalopathy
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Nursing Interventions
1. Maintaining Adequate Fluid Volume
-Monitor vital signs frequently.
- Weigh patient daily and keep an accurate intake and output
record; record frequency and characteristics of stool.
- Measure and record abdominal girth daily.
- Assess and record peripheral edema.
- Restrict sodium and fluids; replace electrolytes as directed
2. Improving Respiratory Status
-Monitor respiratory rate, depth, use of accessory muscles,
nasal flaring, and breath sounds.
-Evaluate ABG values, hemoglobin level, and hematocrit.
-Elevate head of the bed to lower diaphragm and decrease
respiratory effort.
72
3. Improving Nutritional Status
- Encourage patient to eat in a sitting position to
decrease abdominal tenderness and feeling of fullness.
- Provide small, frequent meals or dietary supplements
to conserve patient’s energy.
- Provide mouth care if patient has bleeding gums or
fetor hepaticus.
- Restrict sodium intake and protein based on ammonia
levels and symptoms of encephalopathy
4. Maintaining Skin Integrity
- Inspect skin for alteration in integrity.
- Provide good skin care.
- Bathe without soap and apply soothing lotions.
- Keep patient’s fingernails short to prevent scratching
from pruritus 73
5. Preventing Infection
-Be alert for signs of infection, such as fever, cloudy urine,
abnormal breath sounds.
-Use good hand-washing and aseptic technique when
caring for a break in the skin or mucous membranes.
6. Preventing Injury
-Maintain close observation, bed side rails up, and nurse
call system within reach.
-Assist with ambulation as needed and avoid obstructions
to prevent falls.
-Have well-lit room and frequently reorient patient.
-Observe for subtle changes in behavior
-Restrict visits with anyone who may have an infection.//
74
 CHOLECYSTITIS
- Acute or chronic inflammation of the gallbladder, most
commonly associated with gallstones.
- Inflammation occurs within the walls of the gallbladder and
creates a thickening accompanied by edema.
- Will result to impaired circulation, ischemia and eventually,
necrosis.
Cholelithiasis-formation of gallstones, cholesterol stones most
common variety.
-most commonly occurs in women above 40 years old., in post
menopausal women on estrogen therapy, women taking
contraceptives, obese.
- 4 F (Fat, Female, Forty yrs, Fertile)
-stone formation maybe caused by genetic defect of bile
composition, gallbladder/bile stasis, infection
-Acute cholecyctitis usually follows stone impaction, adhesions
and neoplasm 75
76
 Medical management
1. Supportive treatment: NPO with Nasogastric intubation and IV fluids
2. Diet modifications with administration of fat soluble vitamins
3. Low fat, high CHO diet preferred
4. Drug therapy:
a. Narcotic analgesics (Demerol is the drug of choice) for pain. Morphine
Sulfate is contraindicated because it causes spasms of the sphincter of
Oddi.
b. Anticholinergics such as Atropine. Relax smooth muscle and open bile
ducts
c. Antiemetics such as Metoclopramide (Plasil)
d. Lab: incr. WBC
4. Surgery :
Ø cholecystectomy- surgical removal of the gallbladder
Ø Choledochostomy- surgical incision of the common bile duct usually to
effect /promote drainage

77
4 Assessment Findings:
1. Epigastric or right upper quadrant pain , precipitated by a heavy
meal or occurring at night
2. right upper quadrant pain on palpation (Murphy’s sign)
3. Intolerance for fatty foods (nausea, vomiting, sensation of
fullness)
4.Pruritus, easy bruising, jaundice, dark amber urine and steatorrhea
Diagnostic test:
a. Direct bilirubin, Liver function test, WBC, amylase, lipase all
increased
b. Oral Cholecystogram (gallbladder series) positive for gallstone
Nursing Interventions:
Ø Administer pain medication as ordered
Ø Administer IV fluids as ordered
Ø Provide small frequent meals of modified diet
Ø Provide care to relieve pruritus
Ø Provide care for client with cholecystectomy/choledochostomy
78
Cholecystectomy/Choledochostomy
1. Cholecystectomy- removal of the gallbladder with
insertion of a T-tube into the common bile duct if
common bile duct exploration is performed
2. Choledochostomy- opening of common duct,
removal of stone and insertion of a T-tube
Nursing Interventions:
Ø Routine Preoperative Care
Ø Postoperative Care:
1. Position client in semi-fowler’s or side-lying
positions. Check bleeding/drainage
2. Splint incision when turning, coughing and deep
breathing 79
Laparoscopic Cholecystectomy 80
81
T- Tube: maintain the patency of the CBD 82
83
Maintain/monitor functioning of T-tube:
Purpose : maintain the patency of the CBD
a. Ensure that T-tube is connected to closed gravity drainage
b. Avoid kinks, clamping or pulling of the tube
C. Measure and record drainage every shift
d. Expect 300-500ml. Bile-colored drainage for first 24 hours, then 200
ml./24 hours for 3-4 days
e. Monitor color of urine and stools.
Auscultate abdomen: 4 quadrant (post op)
f. Assess for signs of peritonitis, Intestinal obstruction/pneumonia
Encourage deep breathing and coughing exercise(prevent pneumonia)
post op)
g. Assess skin around T-tube, cleanse frequently and keep dry.
(Clay coloured stool. Yellow sclera, abdo.pain: post cholycystectomy
syndrome)
shallow respirations-indicating pain 84
 Pancreatitis
-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 doudenum which result to tissue
damage and autodigestion of the pancreas
Caused by:
a. Alcoholism e. trauma
b. Biliary tract diseases f. Drugs (steroids & thiazide
diuretics)
c. Viral infection
d. Penetrating duodenal ulcer
Management: stop alcohol intake
1. Drug Therapy
a. Analgesics to relieve pain. Note: Morphine is contraindicated
due to spasmodic effect on the sphincter of Oddi 85
b. Smooth muscle relaxants (Papaverine, nitroglycerine)
c. Anticholinergics (Atropine, Propantheline bromide)
d. Antacids to decrease pancreatic stimulation
e. H2 Antagonists, vasodilators, calcium gluconate
2. Diet modification
3. NPO,NGT
4. Peritoneal lavage
5. Dialysis
Assessment Findings:
a. Pain located in the left upper quadrant which radiates to
back, flank and substernal area maybe accompanied by
difficulty of breathing and aggravated by eating
b. Vomiting
c. shallow respirations
d. Decreased or absent bowel sounds, Inability to pass flatus
86
e. Abdominal tenderness with muscle guarding
f. Positive Grey turner’s spots – ecchymoses on flanks
g. Positive Cullen’s sign – ecchymoses on
periumbilical area
Diagnostic Tests:
1. Serum amylase, lipase, urinary amylase, blood
sugar, lipid levels: Increased/elevated
2. Serum calcium-decreased
3. CT-scan shows enlargement of the pancreas

87
Nursing Interventions:
Ø Administer analgesics, antacids and
anticholinergic as ordered
Ø Maintain NG tube and assess for drainage
Ø Institute non pharmacologic measures to
decrease pain
Ø Dietary regimen when oral intake is permitted
-high carbohydrate, high protein, low fat
-Eat small frequent meals, -Avoiding caffeine
products
-Eliminate alcohol consumption

88
89
 Summary
• percutaneous transhepatic cholangiography complication: septicemia .s/s: fever
chills

• Hepatitis A: food born, good sanitation, Bed rest

• lactulose is effective in decreasing the ammonia level in the client with hepatic
encephalopathy: 2-3 stools per day
Pancreatitis: Positive Grey turner’s spots – ecchymoses on flanks. Positive Cullen’s
sign – ecchymoses on periumbilical area. pancreatic lipase: Breaks down fat into
fatty acids and glycerol . Stop alcohol consumption.
• Spironolactone (Aldactone) : Observe hyperkalemia. I/O
• Hepatic come: check the client is oriented to time, place, and person.
• Hepatic encephalopathy: check hand writing, Hand tremors , s. amonia,
neurological status every 2hry.
• Jaundice : experiencing pruritus: impaired bile acid excretion: cut short nails
• Cholecystitis: right upper quadrant pain on palpation (Murphy’s sign),
Nausea, vomiting, and anorexia. Low-fat, high-carbohydrate meals
• Cirrhosis: Applying pressure to injection sites to control bleeding.
• Avoid taking antacids with other drugs with in 2 hrs. interfere absorption of drug

90
 Self -Study
The client in end-stage liver failure has vitamin K deficiency. Which interventions should
the nurse implement? Select all that apply. 1,2,3,4
1. Avoid rectal temperatures.
2. Use only a soft toothbrush.
3. Monitor the platelet count.
4. Use small-gauge needles.
5. Assess for asterixis.

When caring for a client with advanced cirrhosis, what laboratory assessment findings will
the nurse expect? Select all that apply.
A. Increased serum albumin
B. Decreased bilirubin in the urine
C. Increased alanine aminotransferase
D. Increased alkaline phosphatase
E. Decreased bilirubin in the stool
F. Increased platelets

Answer: C, D 91
The client is four hours postoperative open cholecystectomy
Which data warrant immediate intervention by the nurse?
1. Absent bowel sounds in all four quadrants
2. The T-tube has 60 mL of green drainage
3. Urine output of 100 mL in the past 3 hours
4. Refusal to turn, deep breathe, and cough Answer D
Which problem is highest priority for the nurse to
identify in the client who had an open
cholecystectomy surgery?
1. Alteration in nutrition
2. Alteration in skin integrity
3. Alteration in urinary pattern
4. Alteration in comfort
answer D
92
 Which assessment question is priority for the nurse to ask the client diagnosed with end-
stage liver failure secondary to alcoholic cirrhosis?
1. “How many years have you been drinking alcohol?”
2. “Have you completed an advance directive?”
3. “When did you have your last alcoholic drink?”
4. “What foods did you eat at your last meal?”

The physician assistant prescribes pancreatic enzyme replacement capsules for a client
with chronic pancreatitis. What health teaching will the nurse provide?
A. “Take the enzymes after meals to be most effective.”
B. “Swallow the capsule whole or with applesauce.”
C. “Drink a full glass of milk after taking the drug.”
D. “Crush the capsules and tablets and mix with juice.”

Answer B
93
 Bibliography
• Ignatavicius, D. D., & Workman, L. M. (2013). Medical Surgical
Nursing: Patient-Centered Collaborative Care 7th Edition. Missouri:
Elsevier Saunders. –
• Nettina, S. M. (2010). Lippincott Manual of Nursing Practice 9th
Edition. Wolters Kluwer Health | Lippincott Williams & Wilkins.-
• O'Connell Smeltzer, S. C., & Bare, B. G. (2003). Brunner and
Suddarth's Texbook of Medical-Surgical Nursing, 10th
Edition. Lippincott Williams & Wilkins. -
• Upchurch, S., Henry, T., Pine, R., & Rickles, A. (2014). HESI
Comprehensive Review for the NCLEX - RN Examination 4th
edition. Missouri: Elsevier.-
• Medical surgical suscess
• Saunders NCLEX RN.RM.
• Davis physiological integrity: 94