1
Medsurg II Exam 4 Study Guide
• Gallbladder (pear-shaped, hollow organ that stores 50 mL of bile)
• Functions of Bile:
o Emulsifies fats for absorption
▪ Including FAT SOLUBLE VITAMINS...
• A—vision
• D—bones/low back pain
• E—skin
• K—clotting and bleeding
o Acts as a buffer to neutralize stomach acid
o Excretes bilirubin via GI tract
Unit 9 Part 1: Disorders of the Gallbladder
1. CHOLECYSTITIS pg 1418
• Etiology—usually from stones causing obstructions
o Cholestatic medications—cause stasis and thickening of bile that eventually leads to
obstruction
▪ Phenothiazines, antithyroid meds, sulfonylureas, tricyclic antidepressants,
NITROFURANTOIN, ANDROGENS/ESTROGENS, antibiotics
• RF: diabetes, cystic fibrosis, rapid weight loss, ileal resection or disease, low dose/high dose
estrogen, obesity, Native Americans and SouthWest Hispanic women
• S/S:
o Mild N/V or GI symptoms
o Epigastric fullness⟶ rigidity of RUQ
o Upper abdominal pain that radiates to RIGHT SHOULDER or back
▪ Pain may mimic a heart attack
o Empyema—gallbladder infected and full of pus from leukocytes
▪ Leads to s/s of infection—fever, restlessness, N/V
ACUTE CHOLECYSTITIS
• S/S: fever, restlessness, N/V, jaundice, dark/tea-colored and FROTHY urine,
gray/clay-like stool, vitamin A/E/D/K deficiency
• Diagnostics:
o Ultrasound—shows size of organs and presence of masses (non-invasive, initial step to
diagnose)
o MRCP—visualizes biliary tree and can identify obstructions
o Cholescintigraphy
o Oral cholecystography—visualize gallbladder and bile
o Endoscopic retrograde cholangiopancreatography (ERCP)--visualize biliary
structures and the pancreas
, 2
▪ NURSING CARE: keep patient NPO 6-8 hours prior... done under
conscious sedation
• Assess for return of gag reflux
• start with ice chips/clear liquids and advance diet as tolerated
• Require a ride home/escort for 24 hours after
• Tx:
o Avoid fatty and fried foods including eggs/cream/pork/cheese/rich dressings/gas-forming
veggies/alcohol
o LOW FAT, LIQUID DIET
o Meds to help dissolve stones:
▪ Ursodeoxycholic acid—inhibits synthesis and secretion of cholesterol
▪ Chenodeoxycholic acid
• Both must be taken long term (6 months to 2 years) to effectively
dissolve stones
o Surgical removal of gallbladder/cholecystectomy
▪ NURSING CARE:
• Pain relief is priority
• Encourage breathing exercises/incentive spirometry
• NPO until gag reflex returns
2. BILIARY COLIC
• Patho—swollen and inflamed gallbladder touches abdominal wall while trying to contract
and push bile past obstruction
• S/S: epigastric or RUQ pain with severity dependent on severity of obstruction; jaundice
o Abscesses/perforation/necrosis--indicated by severe and SUSTAINED symptoms
o RESTLESSNESS/PALLOR/DIAPHORESIS/EXHAUSTION = SURGERY
Unit 9 Part 2: Alterations of the Liver
Lab Values:
• Albumin—3.5 to 5
• AST—10 to 40
• ALT—8 to 40
• Ammonia (plasma)--15 to 45
• Bilirubin—less than 2 (greater than 2 = JAUNDICE)
• PT—11 to 13 seconds
• INR—less than 1.1
LIVER DYSFUNCTION
• S/S:
o Jaundice
, 3
▪ From non-conjugating/non-binding bilirubin that builds up
o Hypoalbuminemia
▪ Results in EDEMA and ascites
o Prolonged bleeding times/anemia/easy bruising⟶ clotting factors produced in liver
(fibrinogen/prothrombin)
o Vitamin A/D/E/K deficiency
o Abnormally high/low glucose levels
o Pruritis
o Palmar erythema
o Spider veins—in nose/cheeks/torso/face/UEs above liver from failing to metabolize
circulating estrogen
▪ Additional symptoms from textbook—increasing abdominal girth,
melena/hematemesis/hematochezia (bloody stool), abdominal pain, fever, easy
bruising, anorexia, weight gain/edema, weakness/malaise/fatigue, personality
changes, sleep disturbances, decreased libido in MEN, secondary amenorrhea in
WOMEN
HEPATITIS A (ENTERIC HEPATITIS)
• Route—fecal-oral transmission of virus that is self-limiting
o 2-6 week incubation (peak at 4 weeks)
• S/S (all are worse in adults, but mild in children):
o Flu-like symptoms (low grade fever, upper respiratory symptoms)
o Anicteric during early stages—without jaundice
o Anorexia
o Headache
o Weakness
o LATER SYMPTOMS: dark urine and jaundice that reaches peak at 10 days
o Epigastric pain
o Nausea/flatus/heartburn
o Aversion to cigarettes and strong odors
• Dx:
o HAV antigen from stool—7 to 10 days before symptoms
o Antibody from blood—once symptoms appear
• Prevention:
o HANDWASHING AND HYGEINE
o Proper food and water handling/preparation
▪ Proper sewage disposal
▪ Only bottled water and NO raw produce when out of country
o Vaccinations (2 doses with the 2nd given 6-12 months after the first)
o Immunoglobulin A for at risk family/partners
▪ Keep epinephrine at bedside in case of allergic reaction
• Tx:
o Encourage frequent small meals to support appetite
Medsurg II Exam 4 Study Guide
• Gallbladder (pear-shaped, hollow organ that stores 50 mL of bile)
• Functions of Bile:
o Emulsifies fats for absorption
▪ Including FAT SOLUBLE VITAMINS...
• A—vision
• D—bones/low back pain
• E—skin
• K—clotting and bleeding
o Acts as a buffer to neutralize stomach acid
o Excretes bilirubin via GI tract
Unit 9 Part 1: Disorders of the Gallbladder
1. CHOLECYSTITIS pg 1418
• Etiology—usually from stones causing obstructions
o Cholestatic medications—cause stasis and thickening of bile that eventually leads to
obstruction
▪ Phenothiazines, antithyroid meds, sulfonylureas, tricyclic antidepressants,
NITROFURANTOIN, ANDROGENS/ESTROGENS, antibiotics
• RF: diabetes, cystic fibrosis, rapid weight loss, ileal resection or disease, low dose/high dose
estrogen, obesity, Native Americans and SouthWest Hispanic women
• S/S:
o Mild N/V or GI symptoms
o Epigastric fullness⟶ rigidity of RUQ
o Upper abdominal pain that radiates to RIGHT SHOULDER or back
▪ Pain may mimic a heart attack
o Empyema—gallbladder infected and full of pus from leukocytes
▪ Leads to s/s of infection—fever, restlessness, N/V
ACUTE CHOLECYSTITIS
• S/S: fever, restlessness, N/V, jaundice, dark/tea-colored and FROTHY urine,
gray/clay-like stool, vitamin A/E/D/K deficiency
• Diagnostics:
o Ultrasound—shows size of organs and presence of masses (non-invasive, initial step to
diagnose)
o MRCP—visualizes biliary tree and can identify obstructions
o Cholescintigraphy
o Oral cholecystography—visualize gallbladder and bile
o Endoscopic retrograde cholangiopancreatography (ERCP)--visualize biliary
structures and the pancreas
, 2
▪ NURSING CARE: keep patient NPO 6-8 hours prior... done under
conscious sedation
• Assess for return of gag reflux
• start with ice chips/clear liquids and advance diet as tolerated
• Require a ride home/escort for 24 hours after
• Tx:
o Avoid fatty and fried foods including eggs/cream/pork/cheese/rich dressings/gas-forming
veggies/alcohol
o LOW FAT, LIQUID DIET
o Meds to help dissolve stones:
▪ Ursodeoxycholic acid—inhibits synthesis and secretion of cholesterol
▪ Chenodeoxycholic acid
• Both must be taken long term (6 months to 2 years) to effectively
dissolve stones
o Surgical removal of gallbladder/cholecystectomy
▪ NURSING CARE:
• Pain relief is priority
• Encourage breathing exercises/incentive spirometry
• NPO until gag reflex returns
2. BILIARY COLIC
• Patho—swollen and inflamed gallbladder touches abdominal wall while trying to contract
and push bile past obstruction
• S/S: epigastric or RUQ pain with severity dependent on severity of obstruction; jaundice
o Abscesses/perforation/necrosis--indicated by severe and SUSTAINED symptoms
o RESTLESSNESS/PALLOR/DIAPHORESIS/EXHAUSTION = SURGERY
Unit 9 Part 2: Alterations of the Liver
Lab Values:
• Albumin—3.5 to 5
• AST—10 to 40
• ALT—8 to 40
• Ammonia (plasma)--15 to 45
• Bilirubin—less than 2 (greater than 2 = JAUNDICE)
• PT—11 to 13 seconds
• INR—less than 1.1
LIVER DYSFUNCTION
• S/S:
o Jaundice
, 3
▪ From non-conjugating/non-binding bilirubin that builds up
o Hypoalbuminemia
▪ Results in EDEMA and ascites
o Prolonged bleeding times/anemia/easy bruising⟶ clotting factors produced in liver
(fibrinogen/prothrombin)
o Vitamin A/D/E/K deficiency
o Abnormally high/low glucose levels
o Pruritis
o Palmar erythema
o Spider veins—in nose/cheeks/torso/face/UEs above liver from failing to metabolize
circulating estrogen
▪ Additional symptoms from textbook—increasing abdominal girth,
melena/hematemesis/hematochezia (bloody stool), abdominal pain, fever, easy
bruising, anorexia, weight gain/edema, weakness/malaise/fatigue, personality
changes, sleep disturbances, decreased libido in MEN, secondary amenorrhea in
WOMEN
HEPATITIS A (ENTERIC HEPATITIS)
• Route—fecal-oral transmission of virus that is self-limiting
o 2-6 week incubation (peak at 4 weeks)
• S/S (all are worse in adults, but mild in children):
o Flu-like symptoms (low grade fever, upper respiratory symptoms)
o Anicteric during early stages—without jaundice
o Anorexia
o Headache
o Weakness
o LATER SYMPTOMS: dark urine and jaundice that reaches peak at 10 days
o Epigastric pain
o Nausea/flatus/heartburn
o Aversion to cigarettes and strong odors
• Dx:
o HAV antigen from stool—7 to 10 days before symptoms
o Antibody from blood—once symptoms appear
• Prevention:
o HANDWASHING AND HYGEINE
o Proper food and water handling/preparation
▪ Proper sewage disposal
▪ Only bottled water and NO raw produce when out of country
o Vaccinations (2 doses with the 2nd given 6-12 months after the first)
o Immunoglobulin A for at risk family/partners
▪ Keep epinephrine at bedside in case of allergic reaction
• Tx:
o Encourage frequent small meals to support appetite
