NURSING RNSG Exam 2 Blue Print Edwardo Mata,100% CORRECT

NURSING RNSG Exam 2 Blue Print Edwardo Mata 1. Metabolism/Liver Failure/Nutrition Improving Nutritional Status • The patient with cirrhosis without ascites, edema, or signs of impending hepatic coma should receive a nutritious, high protein diet, if tolerated, supplemented by vitamins of the B complex, as well as A, C, and K. The nurse encourages the patient to eat. If ascites is present, small, frequent meals may be better tolerated than three large meals because of the abdominal pressure exerted by ascites. • Imbalance of the intestinal flora is not uncommon. Research suggests that the oral ingestion of 1 cup of probiotic yogurt three times a day reduces intestinal flora imbalance by decreasing Escherichia coli counts. • Patients with fatty stools (steatorrhea) should receive water-soluble forms of fat-soluble vitamins A, D, and E (Aquasol A, D, and E). Folic acid and iron are prescribed to prevent anemia. If the patient shows signs of impending or advancing coma despite medical interventions, the amount of protein in the diet may be decreased temporarily. o Protein is restricted if encephalopathy develops that cannot be effectively managed with lactulose and other medical treatment strategies. Incorporating vegetable protein to meet protein needs may decrease the risk for encephalopathy. o Sodium restriction is also indicated to prevent ascites. Patients with prolonged or severe anorexia and those who are vomiting or eating poorly for any reason may receive nutrients by the enteral or parenteral route. (Hinkle 1376) A nurse is caring for a patient with liver failure and is performing an assessment in theknowledge of the patient's increased risk of bleeding. The nurse recognizes that this riskis related to the patient's inability to synthesize prothrombin in the liver. What factor most likely contributes to this loss of function? A)Alterations in glucose metabolism B)Retention of bile salts C)Inadequate production of albumin by hepatocytes D)Inability of the liver to use vitamin K Ans:D Feedback:Decreased production of several clotting factors may be partially due to deficientabsorption of vitamin K from the GI tract. This probably is caused by the inability ofliver cells to use vitamin K to make prothrombin A nurse is performing an admission assessment of a patient with a diagnosis ofcirrhosis. What technique should the nurse use to palpate the patient's liver? A)Place hand under the right lower abdominal quadrant and press down lightly with the other hand. B)Place the left hand over the abdomen and behind the left side at the 11th rib. C)Place hand under right lower rib cage and press down lightly with the other hand. D)Hold hand 90 degrees to right side of the abdomen and push down firmly. Ans:C Feedback:To palpate the liver, the examiner places one hand under the right lower rib cage andpresses downward with light pressure with the other hand A nurse is caring for a patient with hepatic encephalopathy. While making the initialshift assessment, the nurse notes that the patient has a flapping tremor of the hands. The nurse should document the presence of what sign of liver disease? A)Asterixis B)Constructional apraxia C)Fetor hepaticus D)Palmar erythema Ans:A Feedback:The nurse will document that a patient exhibiting a flapping tremor of the hands isdemonstrating asterixis. A local public health nurse is informed that a cook in a local restaurant has beendiagnosed with hepatitis A. What should the nurse advise individuals to obtain who ateat this restaurant and have never received the hepatitis A vaccine? A)The hepatitis A vaccine B)Albumin infusion C)The hepatitis A and B vaccines D)An immune globulin injection Ans:D Feedback:For people who have not been previously vaccinated, hepatitis A can be prevented bythe intramuscular administration of immune globulin during the incubation period, ifgiven within 2 weeks of exposure. Administration of the hepatitis A vaccine will notprotect the patient exposed to hepatitis A, as protection will take a few weeks todevelop after the first dose of the vaccine. The hepatitis B vaccine provides protectionagain the hepatitis B virus, but plays no role in protection for the patient exposed tohepatitis A. Albumin confers no therapeutic benefit. A participant in a health fair has asked the nurse about the role of drugs in liver disease.What health promotion teaching has the most potential to prevent drug-induced hepatitis? A)Finish all prescribed courses of antibiotics, regardless of symptom resolution. B)Adhere to dosing recommendations of OTC analgesics. C)Ensure that expired medications are disposed of safely. D)Ensure that pharmacists regularly review drug regimens for potential interactions. Ans:B Feedback:Although any medication can affect liver function, use of acetaminophen (found inmany over-the-counter medications used to treat fever and pain) has been identified asthe leading cause of acute liver failure. A patient has developed hepatic encephalopathy secondary to cirrhosis and is receivingcare on the medical unit. The patient's current medication regimen includes lactulose(Cephulac) four times daily. What desired outcome should the nurse relate to thispharmacologic intervention? A)Two to 3 soft bowel movements daily B)Significant increase in appetite and food intake C)Absence of nausea and vomiting D)Absence of blood or mucus in stool Ans:A Feedback:Lactulose (Cephulac) is administered to reduce serum ammonia levels. Two or threesoft stools per day are desirable; this indicates that lactulose is performing as intended. A patient with liver disease has developed jaundice; the nurse is collaborating with thepatient to develop a nutritional plan. The nurse should prioritize which of the followingin the patient's plan? A)Increased potassium intake B)Fluid restriction to 2 L per day C)Reduction in sodium intake D)High-protein, low-fat diet Ans:C Feedback:Patients with ascites require a sharp reduction in sodium intake. Potassium intakeshould not be correspondingly increased. A nurse is amending a patient's plan of care in light ofthe fact that the patient has recently developed ascites. What should the nurse include in this patient's care plan? A)Mobilization with assistance at least 4 times daily B)Administration of beta-adrenergic blockers as ordered C)Vitamin B12 injections as ordered D) Administration of diuretics as ordered Ans:D Feedback:Use of diuretics along with sodium restriction is successful in 90% of patients withascites. A patient with a diagnosis of esophageal varices has undergone endoscopy to gauge theprogression of this complication of liver disease. Following the completion of thisdiagnostic test, what nursing intervention should the nurse perform? A)Keep patient NPO until the results of test are known. B)Keep patient NPO until the patient's gag reflex returns. C)Administer analgesia until post-procedure tenderness is relieved. D)Give the patient a cold beverage to promote swallowing ability. Ans:B Feedback:After the examination, fluids are not given until the patient's gag reflex returns. A patient with end-stage liver disease has developed hypervolemia. What nursinginterventions would be most appropriate when addressing the patient's fluid volumeexcess? Select all that apply. A)Administering diuretics B)Administering calcium channel blockers C)Implementing fluid restrictions D)Implementing a 1500 kcal/day restriction E)Enhancing patient positioning Ans: A, C, E 2) Metabolism/ Pancreatitis/Diagnostic Findings CHART 50-3Criteria for Predicting Severity of Pancreatitis* Criteria on Admission to Hospital Age >55 years White blood cells (WBCs) >16,000 mm3 Serum glucose >200 mg/dL (>11.1 mmol/L) Serum lactose dehydrogenase (LDH) >350 IU/L (>350 U/L) AST >250 IU/L Criteria Within 48 Hours of Hospital Admission Fall in hematocrit >10% (>0.10) Blood urea nitrogen (BUN) increase >5 mg/dL (>1.7 morning mmol/L) Serum calcium <8 mg/dL (<2 mmol/L) Base deficit >4 mEq/L (>4 mmol/L) Fluid retention or sequestration >6 L Partial pressure of oxygen (PO2) <60 mm Hg (Hinkle 1402) Brunner 13th Edition Assessment and Diagnostic Findings • The diagnosis of acute pancreatitis is based on a history of abdominal pain, the presence of known risk factors, physical examination findings, and diagnostic findings. Serum amylase and lipase levels are used in making the diagnosis of acute pancreatitis, although their elevation can be attributed to many other causes. In most cases, serum amylase and lipase levels are elevated within 24 hours of the onset of the symptoms. • Serum amylase usually returns to normal within 48 to 72 hours, but serum lipase levels may remain elevated for a longer period, often days longer than amylase. Urinary amylase levels also become elevated and remain elevated longer than serum amylase levels. The white blood cell count is usually elevated; hypocalcemia is present in many patients and correlates well with the severity of pancreatitis. Transient hyperglycemia and glucosuria and elevated serum bilirubin levels occur in some patients with acute pancreatitis. • X-ray studies of the abdomen and chest may be obtained to differentiate pancreatitis from other disorders that can cause similar symptoms and to detect pleural effusions. Ultrasound studies, contrast-enhanced CT scans, and magnetic resonance imaging (MRI) scans are used to identify an increase in the diameter of the pancreas and to detect pancreatic cysts, abscesses, or pseudocysts. • Hematocrit and hemoglobin levels are used to monitor the patient for bleeding. Peritoneal fluid, obtained through paracentesis or peritoneal lavage, may contain increased levels of pancreatic enzymes. • ERCP is rarely used in the diagnostic evaluation of acute pancreatitis, because the patient is acutely ill; however, it may be valuable in the treatment of gallstone pancreatitis. (Hinkle ) Brunner 13 edition Assessment and Diagnostic Findings • ERCP is the most useful study in the diagnosis of chronic pancreatitis. It provides details about the anatomy of the pancreas and the pancreatic and biliary ducts. It is also helpful in obtaining tissue for analysis and differentiating pancreatitis from other conditions, such as carcinoma.  Various imaging procedures, including MRI, CT scans, and ultrasound, are used in the diagnostic evaluation of patients with suspected pancreatic disorders. A CT scan or ultrasound study is also helpful to detect pancreatic cysts. • A glucose tolerance test evaluates pancreatic islet cell function and provides necessary information for making decisions about surgical resection of the pancreas. An abnormal glucose tolerance test may indicate the presence of diabetes associated with pancreatitis.  Acute exacerbations of chronic pancreatitis may result in increased serum amylase levels. Steatorrhea is best confirmed by laboratory analysis of fecal fat content. (Hinkle 1408) Brunner 13th edition A patient is being treated on the acute medical unit for acute pancreatitis. The nurse hasidentified a diagnosis of Ineffective Breathing Pattern Related to Pain. Whatintervention should the nurse perform in order to address this diagnosis? A)Position the patient supine to facilitate diaphragm movement. B)Administer corticosteroids by nebulizer as ordered. C)Perform oral suctioning as needed to remove secretions. D)Maintain the patient in a semi-Fowler's position whenever possible. Ans:D Feedback:The nurse maintains the patient in a semi-Fowler's position to decrease pressure on thediaphragm by a distended abdomen and to increase respiratory expansion. A community health nurse is caring for a patient whose multiple health problemsinclude chronic pancreatitis. During the most recent visit, the nurse notes that thepatient is experiencing severe abdominal pain and has vomited 3 times in the pastseveral hours. What is the nurse's most appropriate action? A)Administer a PRN dose of pancreatic enzymes as ordered. B)Teach the patient about the importance of abstaining from alcohol. C)Arrange for the patient to be transported to the hospital. D)Insert an NG tube, if available, and stay with the patient. Ans:C Feedback:Chronic pancreatitis is characterized by recurring attacks of severe upper abdominaland back pain, accompanied by vomiting. A student nurse is caring for a patient who has a diagnosis of acute pancreatitis andwho is receiving parenteral nutrition. The student should prioritize which of the following assessments? A)Fluid output B)Oral intake C)Blood glucose levels D)BUN and creatinine levels Ans:C Feedback:In addition to administering enteral or parenteral nutrition, the nurse monitors serumglucose levels every 4 to 6 hours. **A patient has a recent diagnosis of chronic pancreatitis and is undergoing diagnostictesting to determine pancreatic islet cell function. The nurse should anticipate whatdiagnostic test? A)Glucose tolerance test B)ERCP C)Pancreatic biopsy D)Abdominal ultrasonography Ans:A Feedback:A glucose tolerance test evaluates pancreatic islet cell function and provides necessaryinformation for making decisions about surgical resection of the pancreas. A patient has just been diagnosed with chronic pancreatitis. The patient is underweightand in severe pain and diagnostic testing indicates that over 80% of the patient'spancreas has been destroyed. The patient asks the nurse why the diagnosis was notmade earlier in the disease process. What would be the nurse's best response? A)“The symptoms of pancreatitis mimic those of much less serious illnesses.” B) “Your body doesn't require pancreatic function until it is under great stress, so it is easy to go unnoticed.” C)“Chronic pancreatitis often goes undetected until a large majority of pancreatic function is lost.” D)“It's likely that your other organs were compensating for your decreased pancreatic function.” Ans:C A patient is admitted to the ICU with acute pancreatitis. The patient's family asks whatcauses acute pancreatitis. The critical care nurse knows that a majority of patients withacute pancreatitis have what? A)Type 1 diabetes B)An impaired immune system C)Undiagnosed chronic pancreatitis D)An amylase deficiency Ans:C 3) Metabolism/Pancreatitis/Causes Acute Pancreatitis Causes Gallstones enter the common bile duct and lodge at the ampulla of Vater, obstructing the flow of pancreatic juice or causing a reflux of bile from the common bile duct into the pancreatic duct, thus activating the powerful enzymes within the pancreas. Other less common causes of pancreatitis include bacterial or viral infection, with pancreatitis occasionally developing as a complication of mumps viral infection. Spasm and edema of the ampulla of Vater, caused by duodenitis, can probably produce pancreatitis. Blunt abdominal trauma, peptic ulcer disease, ischemic vascular disease, hyperlipidemia, hypercalcemia, and the use of corticosteroids, thiazide diuretics, oral contraceptives, and other medications have also been associated with an increased incidence of pancreatitis. (Hinkle 1402) Brunner 13th edition In addition, there is a small incidence of hereditary pancreatitis. (Hinkle 1402) Chronic Pancreatitis Causes Alcohol consumption in Western societies and malnutrition worldwide are the major causes of chronic pancreatitis. Smoking is another factor in the development of chronic pancreatitis. Because they are often associated, it is difficult to separate the effects of the alcohol abuse and smoking (Hinkle 1405) A 55-year-old man has been newly diagnosed with acute pancreatitis and admitted tothe acute medical unit. How should the nurse most likely explain the pathophysiology of this patient's health problem? A)“Toxins have accumulated and inflamed your pancreas.” B)“Bacteria likely migrated from your intestines and became lodged in your pancreas.” C)“A virus that was likely already present in your body has begun to attack your pancreatic cells.” D)“The enzymes that your pancreas produces have damaged the pancreas itself.” Ans:D **A patient's assessment and diagnostic testing are suggestive of acute pancreatitis. Whenthe nurse is performing the health interview, what assessment questions address likely etiologic factors? Select all that apply. A)“How many alcoholic drinks do you typically consume in a week?” B)“Have you ever been tested for diabetes?” C)“Have you ever been diagnosed with gallstones?” D)“Would you say that you eat a particularly high-fat diet?” E)“Does anyone in your family have cystic fibrosis?” Ans:A, C A nurse who provides care in a walk-in clinic assesses a wide range of individuals. Thenurse should identify which of the following patients as having the highest risk for chronic pancreatitis? A)A 45-year-old obese woman with a high-fat diet B)An 18-year-old man who is a weekend binge drinker C)A 39-year-old man with chronic alcoholism D)A 51-year-old woman who smokes one-and-a-half packs of cigarettes per day Ans:C A patient is receiving care in the intensive care unit for acute pancreatitis. The nurse isaware that pancreatic necrosis is a major cause of morbidity and mortality in patientswith acute pancreatitis. Consequently, the nurse should assess for what signs or symptoms of this complication? A)Sudden increase in random blood glucose readings B)Increased abdominal girth accompanied by decreased level of consciousness C)Fever, increased heart rate and decreased blood pressure D)Abdominal pain unresponsive to analgesics Ans:C 4) Metabolism/Liver Failure/Nursing Care NURSING DIAGNOSIS: Activity intolerance related to fatigue, lethargy, and malaise Goal: Patient reports decrease in fatigue and reports increased ability to participate in activities 1. Assess level of activity tolerance and degree of fatigue, lethargy, and malaise when performing routine activities of daily living. Provides baseline for further assessment and criteria for assessment of effectiveness of interventions 2. Assist with activities and hygiene when fatigued. Promotes exercise and hygiene within patient’s level of tolerance. 3. Encourage rest when fatigued or when abdominal pain or discomfort occurs. Conserves energy and protects the liver 4. Assist with selection and pacing of desired activities and exercise. Stimulates patient’s interest in selected activities. 5. Provide diet high in carbohydrates with protein intake consistent with liver function. Provides calories for energy and protein for healing. 6. Administer supplemental vitamins (A, B complex, C, and K). Provides additional nutrients. NURSING DIAGNOSIS: Imbalanced nutrition: less than body requirements related to abdominal distention and discomfort and anorexia Goal: Positive nitrogen balance, no further loss of muscle mass; meets nutritional requirements 1. Assess dietary intake and nutritional status through diet history and diary, daily weight measurements, and laboratory data. Identifies deficits in nutritional intake and adequacy of nutritional state. 2. Provide diet high in carbohydrates with protein intake consistent with liver function. Provides calories for energy, sparing protein for healing. 3. Assist patient in identifying low sodium foods. Reduces edema and ascites formation. 4. Elevate the head of the bed during meals. Reduces discomfort from abdominal distention and decreases sense of fullness produced by pressure of abdominal contents and ascites on the stomach. 5. Provide oral hygiene before meals and pleasant environment for meals at mealtime. Promotes positive environment and increased appetite; reduces unpleasant taste. 6. Offer smaller, more frequent meals (6/day). Decreases feeling of fullness, bloating. 7. Encourage patient to eat meals and supplementary feedings. Encouragement is essential for the patient with anorexia and gastrointestinal discomfort. 8. Provide attractive meals and an aesthetically pleasing setting at mealtime. Promotes appetite and sense of wellbeing. 9. Eliminate alcohol. Eliminates “empty calories” and further damage from alcohol. 10. Apply an ice collar for nausea. May reduce incidence of nausea. Administer medications prescribed for nausea, vomiting, diarrhea, or constipation. Reduces gastrointestinal symptoms and discomforts that decrease the appetite and interest in food. 12. Encourage increased fluid intake and exercise if the patient reports constipation. Promotes normal bowel pattern and reduces abdominal discomfort and distention. NURSING DIAGNOSIS: Impaired skin integrity related to pruritus from jaundice and edema Goal: Decrease potential for pressure ulcer development; breaks in skin integrity 1. Assess degree of discomfort related to pruritus and edema. Assists in determining appropriate interventions. 2. Note and record degree of jaundice and extent of edema. Provides baseline for detecting changes and evaluating effectiveness of interventions. 3. Keep patient’s fingernails short and smooth. Prevents skin excoriation and infection from scratching. 4. Provide frequent skin care; avoid the use of soaps and alcohol-based lotions. Removes waste products from skin while preventing dryness of skin. 5. Massage every 2 hours with emollients; turn every 2 hours. Promotes mobilization of edema. 6. Initiate use of alternating-pressure mattress or low air loss bed. Minimizes prolonged pressure on bony prominences susceptible to breakdown. 7. Recommend avoiding the use of harsh detergents. May decrease skin irritation and need for scratching. 8. Assess skin integrity every 4–8 hours. Instruct patient and family in this activity. Edematous skin and tissue have compromised nutrient supply and are vulnerable to pressure and trauma. 9. Restrict sodium as prescribed. Minimizes edema formation. 10. Perform range-of-motion exercises every 4 hours; elevate edematous extremities whenever possible. Promotes mobilization of edema. NURSING DIAGNOSIS: Risk for injury related to altered clotting mechanisms and altered level of consciousness Goal: Reduced risk of injury 1. Assess level of consciousness and cognitive level. Assists in determining patient’s ability to protect self and comply with required self-protective actions; may detect deterioration of hepatic function. 2. Provide safe environment (pad side rails, remove obstacles in room, prevent falls). Minimizes falls and injury if falls occur. 3. Provide frequent surveillance to orient patient, and avoid the use of restraints. Protects patient from harm while stimulating and orienting patient; the use of restraints may disturb patient further. 4. Replace sharp objects (razors) with safer items. Avoids cuts and bleeding. 5. Observe each stool for color, consistency, and amount. Permits detection of bleeding in gastrointestinal tract. 6. Be alert to symptoms of anxiety, epigastric fullness, weakness, and restlessness. May indicate early signs of bleeding and shock. 7. Test each stool and emesis for occult blood. Detects early evidence of bleeding. 8. Observe for hemorrhagic manifestations: ecchymosis, epistaxis, petechiae, and bleeding gums. Indicates altered clotting mechanisms. 9. Record vital signs at frequent intervals, depending on patient acuity (every 1–4 hours). Provides baseline and evidence of hypovolemia and hemorrhagic shock. 10. Keep patient quiet, and limit activity. Minimizes risk of bleeding and straining. 11. Assist physician in passage of tube for esophageal balloon tamponade, if its insertion is indicated. Promotes nontraumatic insertion of tube in anxious and combative patient for immediate treatment of bleeding. 12. Observe during blood transfusions. Permits detection of transfusion reactions (risk increased with multiple blood transfusions needed for active bleeding from esophageal varices). 13. Measure and record nature, time, and amount of vomitus. Assists in evaluating extent of bleeding and blood loss. 14. Maintain patient in fasting state, if indicated. Reduces risk of aspiration of gastric contents and minimizes risk of further trauma to esophagus and stomach by preventing vomiting. 15. Administer vitamin K as prescribed. Promotes clotting by providing fatsoluble vitamin necessary for clotting. 16. Remain with patient during episodes of bleeding. Reassures anxious patient and permits monitoring and detection of further needs of the patient. 17. Offer cold liquids by mouth when bleeding stops (if prescribed). Minimizes risk of further bleeding by promoting vasoconstriction of esophageal and gastric blood vessels. 18. Institute measures to prevent trauma. Promotes safety of patient. a. Maintain safe environment. Minimizes risk of trauma and bleeding by avoiding falls and cuts, etc. b. Encourage gentle blowing of nose. Reduces risk of nosebleed (epistaxis) secondary to trauma and decreased clotting. c. Provide soft toothbrush, and avoid the use of toothpicks. Prevents trauma to oral mucosa while promoting good oral hygiene. Encourage intake of foods with high content of vitamin C. Promotes healing. e. Apply cold compresses where indicated. Minimizes bleeding into tissues by promoting local vasoconstriction. f. Record location of bleeding sites. Permits detection of new bleeding sites and monitoring of previous sites of bleeding. g. Use small-gauge needles for injections. Minimizes oozing and blood loss from repeated injections. 19. Administer medications carefully; monitor for side effects. Reduces risk of side effects secondary to damaged liver’s inability to detoxify (metabolize) medications normally. NURSING DIAGNOSIS: Disturbed body image related to changes in appearance, sexual dysfunction, and role function Goal: Patient verbalizes feelings consistent with improvement of body image and self-esteem 1. Assess changes in appearance and the meaning these changes have for patient and family. Provides information for assessing impact of changes in appearance, sexual function, and role on the patient and family. 2. Encourage patient to verbalize reactions and feelings about these changes. Enables patient to identify and express concerns; encourages patient and significant others to share these concerns. 3. Assess patient’s and family’s previous coping strategies. Permits encouragement of those coping strategies that are familiar to patient and have been effective in the past. 4. Assist and encourage patient to maximize appearance (such as strategies to limit the appearance of jaundice and ascites through careful selection of colors and type of clothing) and explore alternatives to previous sexual and role functions. Encourages patient to continue safe roles and functions while encouraging exploration of alternatives. 5. Assist patient in identifying short-term goals. Accomplishing these goals serves as positive reinforcement and increases self-esteem. 6. Encourage and assist patient in decision making about care. Promotes patient’s control of life and improves sense of well-being and self-esteem. 7. Identify with patient resources to provide additional support (counselor, spiritual advisor). Assists patient in identifying resources and accepting assistance from others when indicated. 8. Assist patient in identifying previous practices that may have been harmful to self (alcohol and drug abuse). Involve patient in goal setting, and provide positive feedback for accomplishments. Recognition and acknowledgment of the harmful effects of these practices are necessary for identifying a healthier lifestyle. NURSING DIAGNOSIS: Chronic pain and discomfort related to enlarged tender liver and ascites Goal: Increased level of comfort 1. Maintain bed rest when patient experiences abdominal discomfort. Reduces metabolic demands and protects the liver. 2. Administer antispasmodic and analgesic agents as prescribed. Reduces irritability of the gastrointestinal tract and decreases abdominal pain and discomfort. 3. Observe, record, and report presence and character of pain and discomfort. Provides baseline to detect further deterioration of status and to evaluate interventions. 4. Reduce sodium and fluid intake if prescribed. Minimizes further formation of ascites. 5. Prepare patient and assist with paracentesis. Removal of ascites fluid 6. Encourage the use of distracting activities such as music, reading, or meditation. Distraction may limit the perception of pain. NURSING DIAGNOSIS: Fluid volume excess related to ascites and edema formation Goal: Restoration of normal fluid volume 1. Restrict sodium and fluid intake if prescribed. Minimizes formation of ascites and edema. 2. Administer diuretic agents, potassium, and protein supplements as prescribed. Promotes excretion of fluid through the kidneys and maintenance of normal fluid and electrolyte balance. 3. Record intake and output every 1 to 8 hours depending on response to interventions and on patient acuity. Indicates effectiveness of treatment and adequacy of fluid intake. 4. Measure and record abdominal girth and weight daily. Monitors changes in ascites formation and fluid accumulation. 5. Explain rationale for sodium and fluid restriction. Promotes patient’s understanding of restriction and cooperation with it. 6. Prepare patient and assist with paracentesis. Paracentesis will temporarily decrease amount of ascites present. NURSING DIAGNOSIS: Confusion related to abnormal liver function and increased serum ammonia level Goal: Improved mental status; safety maintained; ability to cope with cognitive and behavioral changes 1. Restrict dietary protein as prescribed for transient period. Reduces source of ammonia (protein foods). 2. Give frequent, small feedings of carbohydrates. Promotes consumption of adequate carbohydrates for energy requirements and spares protein from breakdown for energy. 3. Protect from infection. Minimizes risk of further increase in metabolic requirements. 4. Keep environment warm and draft free. Minimizes shivering, which would increase metabolic requirements. 5. Pad the side rails of the bed. Provides protection for the patient should hepatic coma and seizure activity occur. 6. Limit visitors. Minimizes patient’s activity and metabolic requirements. 7. Provide careful nursing surveillance to ensure patient’s safety. Provides close monitoring of new symptoms and minimizes trauma to the confused patient. 8. Avoid opioids and barbiturates. Prevents masking of symptoms of hepatic coma and prevents drug overdose secondary to reduced ability of the damaged liver to metabolize opioids and barbiturates; prevents respiratory depression. 9. Awaken at intervals (every 2–4 hours) to assess cognitive status. Provides stimulation to the patient and opportunity for observing patient’s level of consciousness. 10. Identify subtle changes in behavior or sleep–wake pattern (consistent staff caring for the patient enhances this assessment as they become familiar with patient’s baseline). These changes may herald worsening of encephalopathy, which requires rapid intervention, including medication. 11. Assess handwriting or drawing skill daily as indication of cognitive ability. These changes may herald worsening of encephalopathy, which requires rapid intervention, including medication. 12. Encourage patient and family to participate in therapeutic strategies to enhance coping with episodes of mental deterioration. Promoting activities such as listening to music, relaxation techniques, or pre-illness coping strategies can reduce anxiety. 13. Encourage patient and family to discuss feeling of fear, powerlessness, or emotional distress related to patient’s mental deterioration. Actively listening demonstrates caring and concern. NURSING DIAGNOSIS: Risk for imbalanced body temperature: hyperthermia related to inflammatory process of cirrhosis or hepatitis Goal: Maintenance of normal body temperature, free from infection 1. Record temperature regularly (every 4 hours). Provides baseline to detect fever and to evaluate interventions. 2. Encourage fluid intake. Corrects fluid loss from perspiration and fever and increases patient’s level of comfort. 3. Apply cool sponges or ice bag for elevated temperature. Promotes reduction of fever and increases patient’s comfort. 4. Administer antibiotics as prescribed. Ensures appropriate serum concentration of antibiotics to treat infection. 5. Avoid exposure to infections. Minimizes risk of further infection and further increases in body temperature and metabolic rate. 6. Keep patient at rest while temperature is elevated. Reduces metabolic rate. 7. Assess for abdominal pain, tenderness. May occur with bacterial peritonitis. 8. Use sterile technique for all invasive procedures. Many evidence-based practice guidelines (e.g., central venous catheter care) recommend the use of sterile technique to prevent nosocomial infections. NURSING DIAGNOSIS: Ineffective breathing pattern related to ascites and restriction of thoracic excursion secondary to ascites, abdominal distention, and fluid in the thoracic cavity Goal: Improved respiratory status 1. Elevate head of bed to at least 30 degrees. Reduces abdominal pressure on the diaphragm and permits fuller thoracic excursion and lung expansion. 2. Conserve patient’s strength by providing rest periods and assisting with activities. Reduces metabolic and oxygen requirements. 3. Change position every 2 hours. Promotes expansion and oxygenation of all areas of the lungs. 4. Assist with paracentesis or thoracentesis. Paracentesis and thoracentesis (performed to remove fluid from the abdominal and thoracic cavities, respectively) may be frightening to the patient. a. Explain procedure and its purpose to patient. Helps obtain patient’s cooperation with procedures. b. Have patient void before paracentesis. Prevents inadvertent bladder injury. c. Support and maintain position during procedure. Prevents inadvertent organ or tissue injury. d. Record both the amount and the character of fluid aspirated. Provides record of fluid removed and indication of severity of limitation of lung expansion by fluid. e. Observe for evidence of coughing, increasing dyspnea, or pulse rate. Indicates irritation of the pleural space and evidence of pneumothorax or hemothorax. COLLABORATIVE PROBLEM: Gastrointestinal bleeding and hemorrhage Goal: Absence of episodes of gastrointestinal bleeding and hemorrhage 1. Assess patient for evidence of gastrointestinal bleeding or hemorrhage. If bleeding does occur: Allows early detection of signs and symptoms of bleeding and hemorrhage. a. Monitor vital signs (blood pressure, pulse, respiratory rate) every 4 hours or more frequently, depending on acuity. b. Assess skin temperature, level of consciousness every 4 hours or more frequently, depending on acuity. c. Monitor gastrointestinal secretions and output (emesis, stool for occult or obvious bleeding). Test emesis for blood once per shift and with any color change. Hematest each stool. d. Monitor hematocrit and hemoglobin for trends and changes. 2. Avoid activities that increase intraabdominal pressure (straining, turning). Minimizes increases in intra-abdominal pressure that could lead to rupture and bleeding of esophageal or gastric varices. a. Avoid coughing/sneezing. b. Assist patient to turn. c. Keep all needed items within easy reach. d. Use measures to prevent constipation such as adequate fluid intake, stool softeners. e. Ensure small meals. 3. Have equipment (Sengstaken-Blakemore tube™, medications, IV fluids) available if indicated. Equipment, medications, and supplies will be readily available if patient experiences bleeding from ruptured esophageal or gastric varices. 4. Assist with procedures and therapy needed to treat gastrointestinal bleeding and hemorrhage. Gastrointestinal bleeding and hemorrhage require emergency measures (e.g., insertion of Sengstaken-Blakemore tube™, administration of fluids and medications). 5. Monitor respiratory status every hour, and minimize risk of respiratory complications if balloon tamponade is needed. The patient is at high risk for respiratory complications, including asphyxiation if gastric balloon of tamponade tube ruptures or migrates upward. 6. Prepare patient physically and psychologically for other treatment modalities if needed. The patient who experiences hemorrhage is very anxious and fearful; minimizing anxiety assists in control of hemorrhage. 7. Monitor patient for recurrence of bleeding and hemorrhage. Risk of rebleeding is high with all treatment modalities used to halt gastrointestinal bleeding. 8. Keep family informed of patient’s status. Family members are likely to be anxious about the patient’s status; providing information will reduce their anxiety level and promote more effective coping. 9. Once recovered from bleeding episode, provide patient and family with information regarding signs and symptoms of gastrointestinal bleeding. Risk of rebleeding is high. Subtle signs may be more quickly identified. COLLABORATIVE PROBLEM: Hepatic encephalopathy Goal: Absence of changes in cognitive status and of injury 1. Assess cognitive status every 4–8 hours. Data will provide baseline of patient’s cognitive status and enable detection of changes. a. Assess patient’s orientation to person, place, and time. b. Monitor patient’s level of activity, restlessness, and agitation. Assess for presence of flapping hand tremors (asterixis). c. Obtain and record daily sample of patient’s handwriting or ability to construct a simple figure (e.g., star). d. Assess neurologic signs (deep tendon reflexes, ability to follow instructions). 2. Monitor medications to prevent administration of those that may precipitate hepatic encephalopathy (sedative, hypnotic, analgesic agents). Medications are a common precipitating factor in development of hepatic encephalopathy in patients at risk. 3. Monitor laboratory data, especially serum ammonia level. Increases in serum ammonia level are associated with hepatic encephalopathy and coma. 4. Notify physician of even subtle changes in patient’s neurologic assessment, cognitive function, sleep pattern, or mood. Allows early initiation of treatment of hepatic encephalopathy and prevention of hepatic coma. 5. Limit sources of protein from diet if indicated. Reduces breakdown and conversion of protein to ammonia. 6. Administer medications prescribed to reduce serum ammonia level (e.g., lactulose, antibiotics, glucose, benzodiazepine antagonist [flumazenil] if indicated). Reduces serum ammonia level. 7. Assess respiratory status, and initiate measures to prevent complications. The patient who develops hepatic coma is at risk for respiratory complications (i.e., pneumonia, atelectasis, infection). 8. Protect patient’s skin and tissue from pressure and breakdown. The patient in coma is at risk for skin breakdown and pressure ulcer formation. 9. Provide support and active listening for patient and family as patient’s mental status deteriorates. The patient with hepatic encephalopathy can experience episodes of mental deterioration due to liver failure. This can produce feelings of fear and anxiety. (Hinkle ) Brunner 13th edition A patient is being discharged after a liver transplant and the nurse is performingdischarge education. When planning this patient's continuing care, the nurse shouldprioritize which of the following risk diagnoses? A)Risk for Infection Related to Immunosuppressant Use B)Risk for Injury Related to Decreased Hemostasis C)Risk for Unstable Blood Glucose Related to Impaired Gluconeogenesis D)Risk for Contamination Related to Accumulation of Ammonia Ans:A Feedback:Infection is the leading cause of death after liver transplantation. A patient with end-stage liver disease has developed hypervolemia. What nursing interventions would be most appropriate when addressing the patient's fluid volumeexcess? Select all that apply. A)Administering diuretics B)Administering calcium channel blockers C)Implementing fluid restrictions D)Implementing a 1500 kcal/day restriction E)Enhancing patient positioning Ans: A, C, E Feedback:Administering diuretics, implementing fluid restrictions, and enhancing patientpositioning can optimize the management of fluid volume excess. A patient with liver cancer is being discharged home with a biliary drainage system inplace. The nurse should teach the patient's family how to safely perform which of thefollowing actions? A)Aspirating bile from the catheter using a syringe B)Removing the catheter when output is≤15 mL in 24 hours C)Instilling antibiotics into the catheter D)Assessing the patency of the drainage catheter Ans:D *A patient with cirrhosis has experienced a progressive decline in his health; and livertransplantation is being considered by the interdisciplinary team. How will the patient'sprioritization for receiving a donor liver be determined? A)By considering the patient's age and prognosis B)By objectively determining the patient's medical need C)By objectively assessing the patient's willingness to adhere to post-transplantation care D)By systematically ruling out alternative treatment options Ans:B Feedback: The patient would undergo a classification of the degree of medical need through anobjective determination known as the Model of End-Stage Liver Disease (MELD) A patient with liver cancer is being discharged home with a hepatic artery catheter inplace. The nurse should be aware that this catheter will facilitate which of the following? A)Continuous monitoring for portal hypertension B)Administration of immunosuppressive drugs during the first weeks after transplantation C)Real-time monitoring of vascular changes in the hepatic system D)Delivery of a continuous chemotherapeutic dose Ans:D A nurse on a solid organ transplant unit is planning the care of a patient who will soonbe admitted upon immediate recovery following liver transplantation. What aspect of nursing care is the nurse's priority? A)Implementation of infection-control measures B)Close monitoring of skin integrity and color C)Frequent assessment of the patient's psychosocial status D)Administration of antiretroviral medications Ans:A 5) Pancreatitis -Pain Management Pain Management • Adequate administration of analgesia is essential during the course of acute pancreatitis to provide sufficient pain relief and to minimize restlessness, which may stimulate pancreatic secretion further. Pain relief may require parenteral opioids such as morphine, fentanyl (Sublimaze), or hydromorphone (Dilaudid). There is no clinical evidence to support the use of meperidine for pain relief in pancreatitis; in fact, accumulation of its metabolites can cause CNS irritability and possibly seizures. The current recommendation for pain management is the use of opioids, with assessment for their effectiveness and altering therapy if pain is not controlled or increased. More research is needed to identify the best option for pain management in the patient with acute pancreatitis. Antiemetic agents may be prescribed to prevent vomiting. (Hinkle 1403) Nursing Management Relieving Pain and Discomfort • Because the pathologic process responsible for pain is autodigestion of the pancreas, the objectives of therapy are to relieve pain and decrease secretion of pancreatic enzymes. The pain of acute pancreatitis is often very severe, necessitating the liberal use of analgesic agents. The current recommendation for pain management in this population is parenteral opioids, including morphine, hydromorphone, or fentanyl via patient controlled analgesia or bolus. In critically ill patients, a continuous infusion may be needed. Because most opioids stimulate spasm of the sphincter of Oddi to some degree, consensus has not been reached on the most effective agent. Ensuring patient comfort, regardless of the opioid prescribed, is the most essential aspect of care. The nurse frequently assesses the pain and the effectiveness of the pharmacologic (and nonpharmacologic) interventions. Changes may be needed in the regimen for pain management based on the achievement of pain control. Pain assessment tools (see Chapter 12) are available for the nurse to ensure an accurate rating of pain. Nonpharmacologic interventions such as proper positioning, music, distraction, and imagery may be effective in reducing pain when used along with medications. • In addition, oral feedings are withheld to decrease the secretion of secretin. Parenteral fluids and electrolytes are prescribed to restore and maintain fluid balance. Nasogastric suction may be used to relieve nausea and vomiting or to treat abdominal distention and paralytic ileus. The nurse provides frequent oral hygiene and care to decrease discomfort from the nasogastric tube and relieve dryness of the mouth. • The acutely ill patient is maintained on bed rest to decrease the metabolic rate and reduce the secretion of pancreatic and gastric enzymes. If the patient experiences increasing severity of pain, the nurse reports this to the physician because the patient may be experiencing hemorrhage of the pancreas or the dose of analgesic medication may be inadequate. • The patient with acute pancreatitis often has a clouded sensorium because of severe pain, fluid and electrolyte disturbances, and hypoxia. Therefore, the nurse provides frequent and repeated but simple explanations about the need for withholding fluids, maintenance of gastric suction, and bed rest. (Hinkle 1404) Brunner 13th edition A 37-year-old male patient presents at the emergency department (ED) complaining ofnausea and vomiting and severe abdominal pain. The patient's abdomen is rigid, andthere is bruising to the patient's flank. The patient's wife states that he was on a drinkingbinge for the past 2 days. The ED nurse should assist in assessing the patient for what health problem? A)Severe pancreatitis with possible peritonitis B)Acute cholecystitis C)Chronic pancreatitis D)Acute appendicitis with possible perforation Ans:A *A patient with chronic pancreatitis had a pancreaticojejunostomy created 3 months agofor relief of pain and to restore drainage of pancreatic secretions. The patient has cometo the office for a routine postsurgical appointment. The patient is frustrated that thepain has not decreased. What is the most appropriate initial response by the nurse? A)"The majority of patients who have a pancreaticojejunostomy have their normal digestion restored but do not achieve pain relief." B) "Pain relief occurs by 6 months in most patients who undergo this procedure, butsome people experience a recurrence of their pain." C)"Your physician will likely want to discuss the removal of your gallbladder to achieve pain relief." D)"You are probably not appropriately taking the medications for your pancreatitis and pain, so we will need to discuss your medication regimen in detail." Ans:B A patient is being treated on the acute medical unit for acute pancreatitis. The nurse hasidentified a diagnosis of Ineffective Breathing Pattern Related to Pain. Whatintervention should the nurse perform in order to best address this diagnosis? A)Position the patient supine to facilitate diaphragm movement. B)Administer corticosteroids by nebulizer as ordered. C)Perform oral suctioning as needed to remove secretions. D)Maintain the patient in a semi-Fowler's position whenever possible. Ans:D A community health nurse is caring for a patientwhose multiple health problems include chronic pancreatitis. During the most recent visit, the nurse notes that the patient is experiencing severe abdominal pain and has vomited 3 times in the past several hours. What is the nurse's most appropriate action? A)Administer a PRN dose of pancreatic enzymes as ordered. B)Teach the patient about the importance of abstaining from alcohol. C)Arrange for the patient to be transported to the hospital. D)Insert an NG tube, if available, and stay with the patient. Ans:C **A patient has been diagnosed with acute pancreatitis. The nurse is addressing thediagnosis of Acute Pain Related to Pancreatitis. What pharmacologic intervention ismost likely to be ordered for this patient? A)Oral oxycodone B)IV hydromorphone (Dilaudid) C)IM meperidine (Demerol) D)Oral naproxen (Aleve) Ans:B Feedback: The pain of acute pancreatitis is often very severe and pain relief may require parenteral opioids such as morphine, fentanyl (Sublimaze), or hydromorphone (Dilaudid). There is no clinical evidence to support the use of meperidine for pain relief in pancreatitis. A patient has just been diagnosed with chronic pancreatitis. The patient is underweight and in severe pain and diagnostic testing indicates that over 80% of the patient's pancreas has been destroyed. The patient asks the nurse why the diagnosis was not made earlier in the disease process. What would be the nurse's best response? A)“The symptoms of pancreatitis mimic those of much less serious illnesses.” B)“Your body doesn't require pancreatic function until it is under great stress, so it is easy to go unnoticed.” C)“Chronic pancreatitis often goes undetected until a large majority of pancreatic function is lost.” D)“It's likely that your other organs were compensating for your decreased pancreatic function.” Ans:C 6) Pancreatitis- Medical Management Medical Management of Acute Pancreatitis • Management of acute pancreatitis is directed toward relieving symptoms and preventing or treating complications. All oral intake is withheld to inhibit stimulation of the pancreas and its secretion of enzymes. Parenteral nutrition plays an important role in the nutritional support of patients with severe acute pancreatitis, particularly in those who are debilitated and those with a prolonged paralytic ileus (more than 48 to 72 hours) (Townsend et al., 2012; Wu & Conwell, 2010). Ongoing research has shown positive outcomes with the use of enteral feedings. • The current recommendation is that, whenever possible, the enteral route should be used to meet nutritional needs in patients with pancreatitis. This strategy also has been found to prevent infectious complications safely and cost-effectively (Townsend et al., 2012; Wu & Conwell, 2010). Enteral feedings should be started early in the course of acute pancreatitis. Patients who do not tolerate enteral feeding require parenteral nutrition. Nasogastric suction may be used to relieve nausea and vomiting and to decrease painful abdominal distention and paralytic ileus. • Research data do not support the routine use of nasogastric tubes to remove gastric secretions in an effort to limit pancreatic secretion. Histamine-2 (H2) antagonists such as cimetidine (Tagamet) and ranitidine (Zantac) may be prescribed to decrease pancreatic activity by inhibiting secretion of gastric acid. Proton pump inhibitors such as pantoprazole (Protonix) may be used for patients who do not tolerate H2 antagonists or for whom this therapy is ineffective (Karch, 2012). Pain Management • Adequate administration of analgesia is essential during the course of acute pancreatitis to provide sufficient pain relief and to minimize restlessness, which may stimulate pancreatic secretion further.Pain relief may require parenteral opioids such as morphine, fentanyl (Sublimaze), or hydromorphone (Dilaudid) (Rakel&Rakel, 2011). o There is no clinical evidence to support the use of meperidine for pain relief in pancreatitis; in fact, accumulation of its metabolites can cause CNS irritability and possibly seizures. The current recommendation for pain management is the use of opioids, with assessment for their effectiveness and altering therapy if pain is not controlled or increased (Marx, 2009). More research is needed to identify the best option for pain management in the patient with acute pancreatitis (Marx, 2009). Antiemetic agents may be prescribed to prevent vomiting. Intensive Care • Correction of fluid and blood loss and low albumin levels is necessary to maintain fluid volume and prevent renal failure. The patient is usually acutely ill and is monitored in the intensive care unit, where hemodynamic monitoring and arterial blood gas monitoring are initiated. Antibiotic agents may be prescribed if infection is present. o The role of prophylactic antibiotics is controversial and still under study. Insulin may be required if hyperglycemia occurs. Intensive insulin therapy (continuous infusion) in the critically ill patient has undergone much study and has shown promise in terms of positive patient outcomes when compared with intermittent insulin dosing. o Glycemic control with normal or near-normal blood glucose levels improves patient outcomes (Griesdale, 2009). Respiratory Care • Aggressive respiratory care is indicated because of the high risk of elevation of the diaphragm, pulmonary infiltrates and effusion, and atelectasis. Hypoxemia occurs in a significant number of patients with acute pancreatitis, even with normal x-ray findings. Respiratory care may range from close monitoring of arterial blood gases to the use of humidified oxygen to intubation and mechanical ventilation (see Chapter 21 for further discussion). Biliary Drainage • Placement of biliary drains (for external drainage) and stents (indwelling tubes) in the pancreatic duct through endoscopy has been performed to reestablish drainage of the pancreas. This has resulted in decreased pain and increased weight gain. Surgical Intervention • Although the acutely ill patient is at high risk for surgical complications, surgery may be performed to assist in the diagnosis of pancreatitis (diagnostic laparotomy); to establish pancreatic drainage; or to resect or débride an infected, necrotic pancreas. • The patient who undergoes pancreatic surgery may have multiple drains in place postoperatively, as well as a surgical incision that is left open for irrigation and repacking every 2 to 3 days to remove necrotic debris (Fig. 50-6). Postacute Management • Oral feedings that are low in fat and protein are initiated gradually. Caffeine and alcohol are eliminated from the diet. If the episode of pancreatitis occurred during treatment with thiazide diuretics, corticosteroids, or oral contraceptives, these medications are discontinued. • Follow-up may include ultrasound, x-ray studies, or ERCP to determine whether the pancreatitis is resolving and to assess for abscesses and pseudocysts. ERCP may also be used to identify the cause of acute pancreatitis if it is in question and for endoscopic sphincterotomy and removal of gallstones from the common bile duct. Brunner Ch 50 Pg 1408 Medical Management of Chronic Pancreatitis • The management of chronic pancreatitis depends on its probable cause in each patient. Treatment is directed toward preventing and managing acute attacks, relieving pain and discomfort, and managing exocrine and endocrine insufficiency of pancreatitis. Nonsurgical Management • Nonsurgical approaches may be indicated for the patient who refuses surgery, is a poor surgical risk, or when the disease and symptoms do not warrant surgical intervention. Endoscopy to remove pancreatic duct stones, correct strictures, and drain cysts may be effective in selected patients to manage pain and relieve obstruction via ERCP (Trikudanathan et al., 2012). • Management of abdominal pain and discomfort is similar to that of acute pancreatitis; however, the focus is usually on the use of nonopioid methods to manage pain and the implementation of the World Health Organization’s (WHO) three-step ladder for the treatment of chronic pain. This involves initiating monotherapy and, if ineffective, instituting combination therapy with peripherally acting and centrally acting medications. • Antioxidants have shown effect in the relief of pain and in improving quality of life and are often administered to patients with chronic pancreatitis (Trikudanathan et al., 2012). Researchers have proposed that yoga may be an effective nonpharmacologic method for pain reduction and for relief of other coexisting symptoms of chronic pancreatitis (Trikudanathan et al., 2012). Persistent, unrelieved pain is often the most difficult aspect of management (Trikudanathan et al., 2012). • The primary provider, nurse, and dietitian emphasize to the patient and family the importance of avoiding alcohol and foods that have produced abdominal pain and discomfort in the past. The health care team stresses to the patient that no other treatment is likely to relieve pain if the patient continues to consume alcohol. • Diabetes resulting from dysfunction of the pancreatic islet cells is treated with diet, insulin, or oral antidiabetic agents. • The hazard of severe hypoglycemia with alcohol consumption is stressed to the patient and family. Pancreatic enzyme replacement is indicated for the patient with malabsorption and steatorrhea. Surgical Management • Chronic pancreatitis is not often managed by surgery. However, surgery may be indicated to relieve persistent abdominal pain and discomfort, restore drainage of pancreatic secretions, and reduce the frequency of acute attacks of pancreatitis and hospitalization (Trikudanathan et al., 2012). The type of surgery performed depends on the anatomic and functional abnormalities of the pancreas, including the location of disease within the pancreas, the presence of diabetes, exocrine insufficiency, biliary stenosis, and pseudocysts of the pancreas. • Other considerations for surgery selection include the patient’s likelihood for continued use of alcohol and the likelihood that the patient will be able to manage the endocrine or exocrine changes that are expected after surgery. • Pancreaticojejunostomy (also referred to as Roux-en-Y), with a side-to-side anastomosis or joining of the pancreatic duct to the jejunum, allows drainage of the pancreatic secretions into the jejunum. o Pain relief occurs within 6 months in more than 85% of the patients who undergo this procedure, but pain returns in a substantial number of patients as the disease progresses (Trikudanathan et al., 2012). • Other surgical procedures may be performed for different degrees and types of underlying disorders. These procedures include revision of the sphincter of the ampulla of Vater, internal drainage of a pancreatic cyst into the stomach (see later discussion), insertion of a stent, and wide resection or removal of the pancreas. • A Whipple resection (pancreaticoduodenectomy) can be carried out to relieve the pain of chronic pancreatitis (see later discussion under Tumors of the Head of the Pancreas). In an effort to provide permanent pain relief and avoid endocrine and exocrine insufficiency that ensue with major resections of the pancreas, surgeons have designed new procedures that combine limited resection of the head of the pancreas with a pancreaticojejunostomy. o These procedures, known as the Beger or Frey operations, remove most of the head of the pancreas except for a shell of pancreatic tissue posteriorly (Trikudanathan et al., 2012). • When chronic pancreatitis develops as a result of gallbladder disease, surgery is performed to explore the common duct and remove the stones; usually, the gallbladder is removed at the same time. In addition, an attempt is made to improve the drainage of the common bile duct and the pancreatic duct by dividing the sphincter of Oddi, a muscle that is located at the ampulla of Vater (this surgical procedure is known as a sphincterotomy). • A T-tube usually is placed in the common bile duct, requiring a drainage system to collect the bile postoperatively. Nursing care after such surgery is similar to that indicated after other biliary tract surgery. • Approximately two thirds of all patients with chronic pancreatitis can be managed with endoscopic or laparoscopic intervention (Yamada, 2009). Endoscopic and laparoscopic procedures such as distal pancreatectomy, longitudinal decompression of the pancreatic duct, nerve denervation, and stenting have been performed in patients with jaundice or recurrent inflammation and are being refined. • Minimally invasive procedures to treat chronic pancreatitis may prove to be successful adjuncts in the management of this complex disorder (Trikudanathan et al., 2012). • Patients who undergo surgery for chronic pancreatitis may experience weight gain and improved nutritional status; this may result from reduction in pain associated with eating rather than from correction of malabsorption. • However, morbidity and mortality after these surgical procedures are high because of the poor physical condition of the patient before surgery and the concomitant presence of cirrhosis. Even after undergoing these surgical procedures, the patient is likely to continue to have pain and impaired digestion secondary to pancreatitis. A 37-year-old male patient presents at the emergency department (ED) complaining ofnausea and vomiting and severe abdominal pain. The patient's abdomen is rigid, and there is bruising to the patient's flank. The patient's wife states that he was on a drinking binge for the past 2 days. The ED nurse should assist in assessing the patient for what health problem? A)Severe pancreatitis with possible peritonitis B)Acute cholecystitis C)Chronic pancreatitis D)Acute appendicitis with possible perforation Ans:A A home health nurse is caring for a patient discharged home after pancreaticSurgery. The nurse documents the nursing diagnosis Risk for Imbalanced Nutrition: Less thanBody Requirements on the care plan based on the potential complications that mayoccur after surgery. What are the most likely complications for the patient who has had pancreatic surgery? A)Proteinuria and hyperkalemia B)Hemorrhage and hypercalcemia C)Weight loss and hypoglycemia D)Malabsorption and hyperglycemia Ans:D Feedback: The nurse arrives at this diagnosis based on the complications of malabsorption and hyperglycemia. A nurse is creating a care plan for a patient with acute pancreatitis. The care plan includes reduced activity. What rationale for this intervention should be cited in the care plan? A)Bed rest reduces the patient's metabolism and reduces the risk of metabolic acidosis. B) Reduced activity protects the physical integrity of pancreatic cells. C)Bed rest lowers the metabolic rate and reduces enzyme production. D)In activity reduces caloric need and gastrointestinal motility. Ans:C An adult patient has been admitted to the medical unit for the treatment of acutepancreatitis. What nursing action should be included in this patient's plan of care? A)Measure the patient's abdominal girth daily. B)Limit the use of opioid analgesics. C)Monitor the patient for signs of dysphagia. D) Encourage activity as tolerated. Ans:A Feedback:Due to the risk of ascites, the nurse should monitor the patient's abdominal girth. 7) Metabolism/Liver Failure/Nursing Care Brunner Ch 49 pg 1366 Nursing Management • Nursing management for the patient with cirrhosis of the liver is described in detail in Chart49-12. Nursing interventions are directed toward promoting patient’s rest, improving nutritional status, providing skin care, reducing risk of injury, and monitoring and managing potential complications. Promoting Rest The patient with cirrhosis requires rest and other supportive measures to permit the liver to reestablish its functional ability. If the patient is hospitalized, weight and I&O are measured and recorded daily. The nurse adjusts the patient’s position in bed for maximal respiratory efficiency, which is especially important if ascites is marked, because it interferes with adequate thoracic excursion. Oxygen therapy may be required in liver failure to oxygenate the damaged cells and prevent further cell destruction. Rest reduces the demands on the liver and increases the liver’s blood supply. Because the patient is susceptible to the hazards of immobility, efforts to prevent respiratory, circulatory, and vascular disturbances are initiated. These measures may help prevent such problems as pneumonia, thrombophlebitis, and pressure ulcers. After nutritional status improves and strength increases, the nurse encourages the patient to increase activity gradually. Activity and mild exercise, as well as rest, are planned. Improving Nutritional Status The patient with cirrhosis without ascites, edema, or signs of impending hepatic coma should receive a nutritious, highprotein diet, if tolerated, supplemented by vitamins of the B complex, as well as A, C, and K. The nu