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Nursing of Adult Patients with Medical & Surgical Conditions. Gastrointestinal Accessory Organ Disorders. Diagnostic Studies. Serum Bilirubin Test Normal Values Direct bilirubin: 0.1 to 0.3 mg/dl Indirect bilirubin: 0.2 to 0.8 mg/dl Total bilirubin: 0.1 to 1.0 mg/dl

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Nursing of adult patients with medical surgical conditions

Nursing of Adult PatientswithMedical & Surgical Conditions


Accessory Organ


Diagnostic studies
Diagnostic Studies

  • Serum Bilirubin Test

    • Normal Values

      • Direct bilirubin: 0.1 to 0.3 mg/dl

      • Indirect bilirubin: 0.2 to 0.8 mg/dl

      • Total bilirubin: 0.1 to 1.0 mg/dl

      • Total bilirubin in newborns: 1 to 12 mg/dl

    • Rationale

      • Used to diagnose liver disease, biliary obstruction, erythroblastosis fetalis, and hemolytic anemia

    • Nursing Interventions

      • NPO

Diagnostic studies1
Diagnostic Studies

  • Liver Enzyme Tests

    • Normal Values

      • AST (SGOT): 5-40 IU/L

        • elevated with MI, hepatitis, cirrhosis, hepatic necrosis, hepatic tumor, acute pancreatitis, acute renal failure, and acute hemolytic anemia

      • ALT (SGPT): 5-35 IU/L

        • elevated with hepatitis, cirrhosis, hepatic necrosis, hepatic tumors, and hepatotoxic drugs.

      • LDH: 45-90 U/L

        • elevated with MI, pulmonary infarction, hepatic disease, pacreatitis, hemolytic anemia, and skeletal muscle disease.

Diagnostic studies2
Diagnostic Studies

  • Alkaline Phosphatase: 30-85 ImU/L

    • elevated in obstructive disorders of the biliary tract, hepatic tumors, cirrhosis, primary and metastatic tumors, hyperparathyroidism, metastatic tumor in bones and healing fractures

  • Gamma GT: 4-38 U/L

    • elevated with hepatitis, cirrhosis, hepatic tumors, hepatotoxic drugs, MI (4-10 days after), CHF, and alcohol ingestion

  • Rationale

    • Liver is storehouse for many enzymes

    • Injury or diseases affecting the liver will cause release of these enzymes into the bloodstream

  • Diagnostic studies3
    Diagnostic Studies

    • Serum Protein Test

      • Normal Values

        • Total Protein: 6-8 g/dl

        • Albumin: 3.2-4.5 g/dl

        • Globulin: 2.3 to 3.4 g/dl

        • Albumin globulin (A/G ratio): 1.2 to 2.2 g/dl

      • Rationale

        • The liver metabolizes protein, esp. albumin. If the liver is diseased it loses the ability to metabolize the albumin and the serum albumin level is decreased

    Diagnostic studies4
    Diagnostic Studies

    • Oral Cholecystography (Gallbladder Series)

      • Rationale

        • Provides x-ray visualization of the gallbladder after ingestion of a radiopaque dye.

        • The following factors are necessary for adequate dye concentration:

          • Ingestion fo correct number of dye tablets

          • Adequate absorption of the dye from the GI tract; no vomiting or diarrhea

          • Abstinence from food the morning of the test

          • Patency of the cystic duct

          • Concentration of the cye within the gallbladder

    Diagnostic studies5
    Diagnostic Studies

    • Nursing Interventions

      • Assess for allergies to iodine

      • Administer 6 Telepaque tablets orally, after the evening meal

      • NPO after midnight

    Diagnostic studies6
    Diagnostic Studies

    • Intravenous Cholangiography (IV Cholangiogram)

      • Rationale

        • Radiographic dye is administered IV

        • Allows visualization of the hepatic and common bile ducts and also the gallbladder if the cystic duct is patent

        • Used to visualize stones, strictures, or tumors of the hepatic duct, common bile duct, and gallbladder.

    Diagnostic studies7
    Diagnostic Studies

    • Operative Cholangiography

      • Rationale

        • Common bile duct is injected directly with radiopaque dye.

        • Visualization of stones or other obstructions during surgery to prevent unneccessary common bile duct exploration

    Diagnostic studies8
    Diagnostic Studies

    • T-Tube Cholangiogram

      • Rationale

        • Demonstrates good flow of contrast into the duodenum

        • Diagnose retained ductal stones and/or leaks in ducts

      • Nursing Interventions

        • T-tube to closed drainage system

        • Cover site with sterile dressing, if t-tube removed

        • Assess for allergies to iodine

        • NPO after midnight

    Diagnostic studies9
    Diagnostic Studies

    • Ultrasound of the Liver, Gallbladder, and Biliary System

      • Rationale

        • Visualization of deep structures by recording the reflections of ultrasonic waves directed in to the tissue

      • Nursing Interventions

        • NPO after midnight

        • Should be done before barium studies or after all barium has been expelled

    Diagnostic studies10
    Diagnostic Studies

    • Gallbladder Scanning

      • Rationale

        • Injection of technetium 99 is given and scan is done to visualize the gallbladder and biliary tract

        • Used to diagnose acute cholecystitis

      • Nursing Interventions

        • NPO after midnight

    Diagnostic studies11
    Diagnostic Studies

    • Liver Biopsy

      • Rationale

        • Needle is inserted through the abdominal wall into the liver to remove a piece of liver tissue

        • Used to diagnose cirrhosis, hepatitis, drug-related reactions, granuloma, and tumors

      • Nursing Interventions

        • Informed consent

        • NPO for 4-8 hours

        • Assess lab results for normal platelet count and prothrombin time

    Diagnostic studies12
    Diagnostic Studies

    • After biopsy

      • Assess for s/s of bleeding

      • Vital signs every 15 min x 1hr, every 30 min x 4 hrs, then every 4 hrs

      • Assess for s/s of pneumothorax

      • Bed rest for 24 hrs

    Diagnostic studies13
    Diagnostic Studies

    • Liver Scanning

      • Rationale

        • Radionuclide is given IV

        • Geiger counter is used to record the distribution of radioactive particles in the liver

      • Nursing Interventions

        • NPO after midnight

    Diagnostic studies14
    Diagnostic Studies

    • Blood Ammonia

      • Normal Value

        • 15 to 110 micrograms/dl

      • Rationale

        • Ammonia is normally converted into urea and then excreted by the kidneys

        • Liver dysfunction or altered blood flow to the liver causes blood ammonia levels to rise and BUN (blood urea nitrogen) to decrease

      • Nursing Interventions

        • Notify lab if patient is currently taking Neomycin; can cause decreased ammonia levels

    Diagnostic studies15
    Diagnostic Studies

    • Hepatitis Virus Studies

      • Rationale

        • Diagnose specific virus causing hepatitis

          • A, B, C, D, and E

    Diagnostic studies16
    Diagnostic Studies

    • Serum Amylase Test

      • Normal Value

        • 25 to 125 U/L

      • Rationale

        • Damage to pancreas cells or obstruction to the pancreatic ductal flow will cause an outporing of this enzyme and absorption into the bloodstream

        • Levels will rise within 12 hours of onset of pancreatic disease.

        • Rapidly cleared by the kidneys; levels may return to normal within 48-72 hrs

      • Nursing Interventions

        • Note administration of any IV dextrose; can cause a false-negative result

    Diagnostic studies17
    Diagnostic Studies

    • Urine Amylase Test

      • Normal Value

        • 3-35 IU/hr

      • Rationale

        • Disorders affecting the pancreas will cause elevated amylase levels in the urine because the kidneys rapidly clear amylase

        • Levels remain elevated in the urine for 7-10 days

        • Used to diagnose pancreatitis in patients who have had symptoms for 3 days or longer

    Diagnostic studies18
    Diagnostic Studies

    • Nursing Interventions

      • Urine collection may be 2 hr spot urine, 6 hr, 12 hr, or 24 hr collection.

        • Record exact time collection is begun

        • Discard first urine specimen

        • Collect all subsequent urine, including the last urine voided exactly 2, 6, 12, or 24 hrs after collection began

        • Urine should be kept on ice during collection period

    Diagnostic studies19
    Diagnostic Studies

    • Ultrasound of Pancreas

      • Rationale

        • Provides diagnostic information with the use of ultrasonography of the pancreas

        • Used to diagnose carcinoma, pseudocyst, pancreatitis, and pancreatic abcess

      • Nursing Interventions

        • NPO for 8 hours before test

        • Gas or barium will interfere with sound wave transmission

    Diagnostic studies20
    Diagnostic Studies

    • Computerized Tomography of the Abdomen

      • Rationale

        • Cross-sectional image

        • Used to diagnose inflammation, tumors, cysts, ascites, aneurysm, and cirrhosis of the liver

      • Nursing Interventions

        • NPO after midnight

        • Some patients may experience claustrophobia

    Diagnostic studies21
    Diagnostic Studies

    • Endoscopic Retrograde Cholangiopancreatography of the Pancreatic Duct (ERCP)

      • Rationale

        • A fiberoptic duodenoscope is inserted through the oral pharynx, through the esophagus and stomach, and into the duodenum. Dye is injected for radiographic visualization of the CBD and pancreatic duct.

        • Used to diagnose obstructive jaundice, remove common bile duct stones, and place biliary and pancreatic duct stents to bypass obstructions

    Diagnostic studies22
    Diagnostic Studies

    • Nursing Interventions

      • NPO for 8 hours before test

      • Informed consent

      • Must remain still for 1-2 hours

      • After procedure

        • NPO until gag reflex returns

        • Assess for abdominal pain, tenderness and guarding

        • Assess for s/s of pancreatitis

          • abd. pain, nausea, vomiting, and diminished or absent bowel sounds


    • Etiology/Pathophysiology

      • Chronic, degenerative disease of the liver

      • Scar tissue restricts the flow of blood to the liver

      • Types of cirrhosis

        • Laennec’s cirrhosis

          • history of chronic ingestion of alcohol

        • Postnecrotic cirrhosis

          • viral hepatitis, exposure to hepatotoxins, or infection

        • Primary biliary cirrhosis

          • destruction of the bile ducts

        • Secondary biliary cirrhosis

          • chronic biliary tree obstruction (gallstones, tumor, etc.)


    • Alteration of liver function

      • Reduced ability to metabolize albumin

      • Obstruction of portal vein

      • Increased pressure in the veins that drain the GI tract

    • Complications

      • Portal Hypertension

        • increased venous pressure in the portal circulation caused by compression or occlusion in the portal or hepatic vascular system

    • Ascites

      • accumulation of fluid and albumin in the peritoneal cavity

    • Esophageal Varicosities

      • veins in the upper part of the body distend, including the esophageal veins due to portal hypertension. They may rupture causing severe hemorrhage


    • Hepatic Encephalopathy

      • Brain damage due to elevated ammonia levels

      • Inaapropriate behavior, disorientation, flapping hand tremors, twitching of the extremities, stupor, and coma


    • Signs & Symptoms

      • Early stages

        • Abdominal pain

        • Liver is firm and easy to palpate

      • Late stages

        • dyspepsia

        • changes in bowel habits

          • constipation or diarrhea

        • Nausea and vomiting

        • gradual weight loss


    • ascites

    • enlarged spleen

    • spider angiomas

    • anemia

    • bleeding tendencies

      • cannot absorb vitamin K, or produce clotting factors

    • epistaxis

    • purpura

    • hematuria

    • bleeding gums


    • jaundice

      • yellow discoloration of the skin, mucous membranes and sclerae or the eyes

      • caused by abnormal amounts of bilirubin in the blood

    • mental disorientation


    • Treatment

      • Eliminate the cause

        • alcohol, hepatotoxins, environmental exposure to harmful chemicals

      • Diet

        • Well balanced

        • High-calorie (2500 to 3000 cal/day)

        • Moderate protein (75 g/day)

        • Low fat

        • Low sodium (1000 to 2000 mg/day)

        • Supplemental vitamins and folic acid


    • Antiemetics

      • Benadryl & Dramamine

      • Contraindicated: Vistaril, Compazine, and Atarax

    • Treatment of Complications

      • Ascites

        • Bedrest

        • Strict I&O

        • Restrict fluids to 500 -1000 cc/day

        • Restrict sodium to 1000-2000 mg/day

        • Diuretics: Aldactone, Lasix, HCTZ

        • Vitamin Supplements: Vitamin K, Vitamin C and folic acid

        • LeVeen Peritoneal-Jugular Shunt

        • Paracentesis


    • Ruptured Esophageal Varices

      • Maintain airway

      • Establish IV

      • Vasopressin drip to control bleeding

        • IV or directly into the superior vena cava

      • Sengstaken-Blakemore tube

      • Endoscopic sclerotherapy

      • Portacaval shunt

        • divert blood from the portal vein to the inferior vena cava

      • Blood transfusion


    • Hepatic Encephalopathy

      • Decrease protein in diet

      • Avoid drugs which are detoxified by the liver

      • Lactulose

        • Oral or retention enema

        • decreases the pH of the bowel which decreases the production of ammonia

      • Neomycin

        • inhibits protein synthesis in bacteria, therefore decreasing the production of ammonia


    • Etiology/Pathophysiology

      • Inflammation of the liver resulting from several types of viral agents or exposure to toxic substances

      • Hepatitis A

        • Most common

        • Incubation 10-40 days

        • Oral-fecal trasmission


    • Hepatitis B

      • Incubation 28-160 days

      • Transmission by contaminated serum; blood transfusion, contaminated needles, dialysis, or direct contact with infected body fluids

    • Hepatitis C

      • Incubation 2 weeks to 6 months (usually 6-9 weeks)

      • Transmitted through contaminated needles and blood transfusions

    • Hepatitis D

      • Coinfection with hepatitis B

      • Incubation 2-10 weeks


    • Hepatitis E

      • Fecal contamination of water

      • Rare in the U.S.; usually in developing countries

      • Incubation 15-64 days


    • Signs & Symptoms

      • General malaise

      • Aching muscles

      • Photophobia

      • Headaches

      • Chills

      • Abdominal pain

      • Dyspepsia

      • Nausea


    • Diarrhea

    • Constipation

    • Pruritus

    • Hepatomegaly

    • Enlarged lymph nodes

    • Weight loss

    • Jaundice

    • Dark amber urine

    • Clay colored stools


    • Treatment

      • Treat signs and symptoms

      • Small frequent meals

        • low-fat, high carbohydrate

      • IV fluids for dehydration

        • Vitamin C for healing

        • Vitamin B-complex for absorption of fat soluble vitamins

        • Vitamin K for coagulation

      • Avoid unnecessary medications, esp seditives


    • Gamma globulin or immune serum globulin

      • should be given to anyone exposed to Hepatitis A

      • may be given 2 weeks before and 1 week after onset of symptoms

    • Hepatitis B imune globulin (HBIG)

      • should be given to anyone exposed to Hepatitis B

    • Hepatitis B Vaccine

      • should be given to persons identified as high risk for developing Hepatitis B

        • healthcare personnel

        • high-risk lifestyle (drug users, homosexual men, prostitutes)

        • infants born to mothers who are Hepatitis B positive

    Liver abscesses
    Liver Abscesses

    • Etiology/Pathophysiology

      • May be single of multiple

      • Abscess forms in the liver due to an invading bacteria

    Liver abscesses1
    Liver Abscesses

    • Signs & Symptoms

      • Fever

      • Chills

      • Abdominal pain and tenderness in the RUQ

      • Hepatomegaly

      • Jaundice

      • Anemia

    Liver abscesses2
    Liver Abscesses

    • Treatment

      • IV antibiotics

      • Percutaneous drainage of liver abscess

      • Open surgical drainage

    Cholecystitis cholelithiasis
    Cholecystitis & Cholelithiasis

    • Etiology/Pathophysiology

      • An obstruction, gallstone, or tumor prevents bile from leaving the gallbladder and the trapped bile acts as an irritant causing inflammation.

      • Risk factors:

        • Female

        • Native American or white

        • Obesity

        • Pregnancy

        • Diabetes

        • Multiparous women

        • Use of birth control

    Cholecystitis cholelithiasis1
    Cholecystitis & Cholelithiasis

    • Signs & Symptoms

      • Indigestion after eating foods high in fat

      • Severe, colicky pain in the right upper quadrant

        • may radiate around the midtorso to the right scapular area

      • Anorexia

      • Nausea & vomiting

      • Flatulence

      • Increased heart & respiratory rates

      • Diaphoresis

    Cholecystitis cholelithiasis2
    Cholecystitis & Cholelithiasis

    • Low grade fever

    • Elevated WBC

    • Mild jaundice

    • Steatorrhea (fatty stool)

    • Dark amber urine

    Cholecystitis cholelithiasis3
    Cholecystitis & Cholelithiasis

    • Treatment

      • Mild attacks

        • Bedrest

        • NG tube to suction

        • NPO

        • IV fluids

        • Antispasmodic/Analgesic

          • Demerol: decreases incidence of spasms of the sphincter of Oddi

        • Antibiotics

        • Avoid spicy foods when allowed PO intake

    Cholecystitis cholelithiasis4
    Cholecystitis & Cholelithiasis

    • Lithtripsy

      • A machine discharges a series of shock waves through water or a cushion that breaks the stone into fragments

    • Cholecystectomy (Removal of the gallbladder)

      • Laparoscopic

        • Oral liquids post-op

        • Outpatient or discharged next day

        • Resume moderate activity in 48-72 hrs

      • Open

        • Jackson-Pratt drain

        • T-tube

        • NG tube

        • Routine post-op care


    • Etiology/Pathophysiology

      • Inflammation of the pancreas

        • Acute or Chronic

      • Predisposing Factors

        • Alcohol

        • Trauma

        • Infectious disease

        • Certain drugs

      • Obstruction of the pancreatic duct may cause a rupture and enzymes digest the pancreas


    • Signs & Symptoms

      • Abdominal pain

      • Anorexia

      • Nausea & vomiting

      • Malaise

      • Restlessness

      • Low-grade fever

      • Jaundice

      • Weight loss

      • Steatorrhea

      • Tachycardia


    • Treatment

      • NPO

      • IV fluids

      • NG tube

      • Antiemetics

      • Demerol 75 -100 mg q 3-4 hrs

        • Avoid morphine; causes spasms of the sphincter of Oddi

      • Anticholinergics

        • atropine or Pro-Banthine

    • Antacids or Tagamet (prevent ulcers)


    • Hyperalimentation

      • may be required to maintain nutrition

    • Prevention

      • bland, low-fat, high-protein, high-carbohydrate diet

      • no alcohol or gastric stimulants (coffee)

      • may need oral hypoglycemic agents if destruction or the islets of Langerhans

    Cancer of the pancreas
    Cancer of the Pancreas

    • Etiology/Pathophysiology

      • Unknown

      • Risk factors

        • cigarette smoking

        • exposure to chemical carcinogens

        • diabetes mellitus

        • pancreatitis

        • diet high in meat, fat and coffee

      • May be metastisis form the lung, stomach, duodenum or CBD

      • May live only 4-8 months after diagnosis

    Cancer of the pancreas2
    Cancer of the Pancreas

    • Signs & Symptoms

      • Anorexia

      • Fatigue

      • Nausea

      • Flatulence

      • Change in stools

      • Steady, dull aching pain in the epigastic area

      • Weight loss

      • Jaundice

      • Onset of diabetes mellitus

    Cancer of the pancreas3
    Cancer of the Pancreas

    • Treatment

      • Surgery

        • Whipple procedure

          • resection of the antrum of the stomach, duodenum, and part of the pancreas

          • anastomosis between the stomach, CBD, and pancreatic ducts and the jejunum

        • Total pancreatectomy with resection of parts of the GI tract

      • Chemotherapy

        • 5-FU and BCNU

        • Gemzar

    • Radiation