Primary Nursing Diagnosis

Pain (acute) related to obstruction of biliary tree

OUTCOMES. Comfort level; Pain control behavior; Pain level; Symptom severity

INTERVENTIONS. Analgesic administration; Anxiety reduction; Environmental management: Comfort; Pain management; Medication management; Patient-controlled analgesia assistance

Gallbladder and Biliary Duct (Biliary System) Cancer 355

^ PLANNING AND IMPLEMENTATION Collaborative

MEDICAL. Most medical treatment is aimed at supportive care, such as controlling the GI symptoms and the discomforts of jaundice.

SURGICAL. A cholecystectomy is done as soon as possible after the cancer is detected, although the cancer may have been found by doing the surgery for cholecystitis. Surgery may include removal of a section of the liver. Internal radiotherapy, using iridium-129 wire or radium needles, may be combined with biliary drainage. Chemotherapy has not been shown to be effective against this cancer. External radiation may be used palliatively for cancer of the bile duct but is not effective against gallbladder cancer. If the tumor is inoperable or increases in size after surgery and is occluding any of the bile ducts, palliative measures may be taken to allow the bile to flow into the duodenum. Drainage of the bile can be accomplished by an external system, similar to that of a T-tube, or an internal stent that drains directly into the duodenum. As an alternative to surgery, a stent made of specialized plastic or steel is placed either by endoscopy or per-cutaneously through the tumor to allow drainage of the trapped bile. Complications include cholangitis and obstruction and dislocation of the stent.

DIETARY. Dietary changes are similar to those needed by patients with cholelithiasis, except the emphasis is on gaining weight rather than on weight reduction. A diet balanced with high calories and protein and low fat helps control the GI symptoms. Each individual needs to determine what foods are best tolerated. Medications to control nausea may be needed before meals, and the patient usually needs a pain-control regimen.

Pharmacologic Highlights

Medication or Drug Class

Dosage

Description Rationale

Narcotic analgesia

Varies with drug

Drugs such as morphine sulfate or Demerol Controls pain may be used to control pain after surgery

Independent

The nurse has an important role in maximizing the patient's comfort. To augment the pain control obtained from analgesia, initiate nonpharmacologic strategies. Allow the patient to participate in the activities of daily living as much as possible. Assist with personal hygiene as much as needed, and include the significant others in learning the process. The itching associated with pruritus can be controlled by maintaining skin integrity, using soft, dry linens and cloths and warm water for bathing. Keep the area around all surgical incisions and drainage devices clean and dry. A large number of support groups exist to help patients and families manage cancer. Listen to the patient's concerns. Give the patient and family the number for the American Cancer Society and hospice care if appropriate.

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