Critical Thinking Exercise No.

8 (Assessment and Management of Patients With Biliary

Disorders)
1. A 77-year-old man underwent a right total hip replacement. His clinical course was initially stable
but on day 4 postoperatively he became nauseated and began vomiting. He also complained of
right upper quadrant pain and was hypotensive and tachycardic. His urine output has decreased
to 10 mL/hr. What are the initial priorities of care for this patient? An abdominal ultrasound and
abdominal CT scan were performed and revealed marked thickening of the gallbladder wall and
pericholecystic effusion but no gallstones were identified. He was determined to have acalculous
cholecystitis. What would be the initial treatment the nurse would expect to implement? If the
patient continued to deteriorate with worsening pain and signs of systemic inflammation and
hypovolemia, what additional interventions should the nurse be prepared to implement?
Questions Answer
a) What are the initial  Maintenance of fluid balance.
priorities of care for this  Hypotension and tachycardia with decreased urine
patient? output are indicators of fluid volume deficit. This
causes impaired tissue perfusion and may result to
shock in severe cases.

b) What would be the initial  Pharmacologic treatment or interventions is done. This

treatment the nurse includes antobiotic therapy to manage mild to moderate
would expect to infection and administration of analgesic for pain
implement? management as prescribed.
c) If the patient continued to  Pharmacological and non-pharmacological intervention
deteriorate with should be carried out, this includes:
worsening pain and signs a. Monitor input and output
of systemic inflammation b. Administration of IV therapy to improve tissue perfusion
and hypovolemia, what c. Maintenance of fluid balance
additional interventions d. Administration of analgesics for pain management
should the nurse be e. Monitor normal levels of liver profile
prepared to implement? f. Provide distraction techniques, imagery, and relaxation
texhniqures
g. Assess body temperation
2. A 58-year-old man presents to the emergency department with complaints of severe
midepigastric pain. He is also nauseated and vomiting. His vital signs reveal hypotension and
tachycardia and he is febrile. His history is significant for alcohol abuse and hypertension. What
laboratory and imaging studies do you expect to be performed? His CT scan revealed pancreatic
necrosis and multiple fluid collections. An evidence-based approach for managing infected
pancreatic necrosis was implemented. What first-line intervention would you expect to be
implemented in this case? What classification of pancreatitis is this patient experiencing?
Questions Answer
a) What laboratory and  Serum lipase and amylase levels
imaging studies do you  Imaging studies (X-ray, Ultrasound, CT scan, MRI)
expect to be performed?  CBC
 b) What first-line
intervention would you
expect to be implemented
in this case?
c) What classification of
pancreatitis is this patient
experiencing?
 Relieving pain
 Maintaining Adequate Fluid Balance
 Improving Respiratory Function
 Diet or Nutrition
 Maintaining Skin Integrity
 Educating patient about potential complications with
monitoring and management
 The patient is experiencing Acute Pancreatitis. Specifically a
Necrotizing pancreatitis as the CT scan revealed pancreatic
necrosis.

3. A 55-year-old woman has been experiencing upper abdominal pain for several weeks. She
believes that she has gallbladder disease but is concerned because her mother died from
pancreatic cancer. She visits her physician who prescribes a CT scan and initial laboratory
screening studies. Which laboratory tests would you expect to be assessed? The CT scan
revealed no masses but did show dilatation of the pancreatic duct. The woman grew more
concerned due to her family history even though her initial laboratory tests were normal. Her
physician shared her concern and prescribed an MRI, which revealed a small mass at the head of
the pancreas. The woman was referred to a surgeon who began an assessment to determine if
the patient was a candidate for potentially curative resection. What testing is needed to assess if
the mass was cancerous and if it may have metastasized? The patient is determined to be a
candidate for surgery. List two postoperative nursing interventions that can be effective in
preventing complications. What education will the nurse provide the patient to enhance comfort,
nutrition and quality of life after discharge?
Questions Answer
a. Which laboratory tests  CBC
would you expect to be  Serum lipase and amylase levels
assessed?  Urinalysis and blood examination for calcium, glucose, and
serum bilirubin level
b. What testing is needed to  Spiral (helical) CT - 85% to 90% accurate in diagnosis and
assess if the mass was staging of pancreatic cancer
cancerous and if it may  MRI
have metastasized?  Endoscopic retrograde cholangiopancreatography (ERCP) -
used in diagnosis of pancreatic carcinoma
 Percutaneous fine-needle aspiration biopsy
 Endoscopic Ultrasound (EUS) - useful in identifying small
tumors and in performing Percutaneous fine-needle aspiration
biopsy
c. List two postoperative  The nursing interventions that can be effective in preventing
nursing interventions that complications are:
can be effective in a. Monitoring and caring for the wound site to prevent
preventing complications. complications (infections); Assess the drain for quantity,
size, and maintenance of skin integrity.
b. Monitor v/s and hemodynamics
d. What education will the  Educate the patient and their significant other about the
nurse provide the patient to dietary modifications which includes low-fat diet.
enhance comfort, nutrition  Educate the patient for the proper pain management and
and quality of life after wound care.
discharge?  Educate the patient about the possible complicatios and to
report if any complications associated with surgery or wound is
present.