Cholelithiasis and Cholecystitis Flashcards
1
Q
cholecystitis
A
- inflammation of the gallbladder wall
- Most often caused by gallstones (cholelithiasis) obstructing the cystic and/or common bile ducts (bile flows from the gallbladder to the duodenum) causing bile to back up and the gallbladder to become inflamed
- Can be acute or chronic
- Can obstruct the pancreatic duct–>pancreatitis
- Can cause the gallbladder to rupture–>secondary peritonitis
2
Q
cholelithiasis
A
- presence of stones in the gallbladder related to the precipitation of either bile or cholesterol into stones
- Bile is used for digestion of fats
- It is produced in the liver and stored in the gallbladder
3
Q
cholelithiasis/cystitis: health promotion & dz prevention
A
- Consume low fat diet rich in HDL (seafood, nuts, olive oil)
- Participate in regular exercise program
- Do not smoke
4
Q
cholelithasia/cystitis: risk factors
A
- Females: hormone therapy and use of some oral contraceptives
- High fat diet
- Obesity: impaired metabolism, high cholesterol
- Genetic predisposition
- Older adults: dec contractility
- Type 2 DM (high triglycerides) or Crohn’s
- Low calorie, liquid protein diets
- Rapid weight loss: inc cholesterol
- Native Americans or Mexican ethnicity
5
Q
cholelithaisis/cystitis: expected findings
A
- Sharp pain in the RUQ, often radiating to right shoulder
- Pain w/ deep inspiration during right subcostal palpation: Murphy’s Sign
- Intense pain: inc HR, pallor, diaphoresis–w/ n/v after ingestion of high fat food caused by biliary colic
- Rebound tenderness: Blumberg’s sign performed by provider
- Dyspepsia, eructation (belching), flatulence
- Fever
- Jaundice, clay colored stools, steatorrhea (fatty stools), dark urine, pruritis in clients with chronic cholecystitis
- Older adults: if they have DM, can have atypical presentation–>absence of pain/fever
6
Q
cholelithiasis/cystitis: lab tests
A
- Inc WBC–>inflammation
- Direct, indirect, and total serum bilirubin increased if bile duct obstructed
- Amylase and lipase inc w/ pancreatic involvement
- AST, LDG, and ALP–>inc w/ liver dysfunction and can indicate common bile duct is obstructed
7
Q
cholelithaisis/cystitis: diagnostic procedures
A
- U/S: visualize gallstones and a dilated common bile duct
- Abdominal x-ray or CT scan: visualize calcified gallstones and an enlarged gallbladder
- Hepatobiliary scan (HIDA): assesses patency of biliary duct system after an IV injection of contrast
- Endoscopic retrograde cholangiopancreatography: allows for direct visualization using an endoscope that is inserted thru the esophagus to common bile duct via duodenum
- A sphincterotomy w/ gallstone removal can be done during this procedure
- Magnetic resonance cholangiopancreatography: combines use of oral/IV contrast with an MRI
- Assess in determining cause
8
Q
cholelithiasis/cystitis: meds
A
- analgesics
- bile acids
9
Q
cholelithiasis/cystitis: analgesics
A
- Opioid analgesics (morphine sulfate or hydromorphone)
- Preferred for acute biliary pain
- NSAIDs (ketorolac)
- For mild to moderate pain
- Monitor for GI bleeding
10
Q
cholelithiasis/cystitis: bile acids
A
- chenodiol, ursodiol
- Gradually dissolves cholesterol based gallstones
- Nursing Considerations:
- Use caution if client has liver condition or disorders w/ varices
- Client Edu:
- Teach clients to report abdominal pain, diarrhea, or vomiting
- Limited to 2 yrs administration and requires a gallbladder U/S every 6 mos during 1st year to determine effectiveness
11
Q
cholelithiasis/cystitis: list the therapeutic procedures
A
- extracorporeal shock wave lithotripsy
- cholecystectomy
12
Q
cholelithiasis/cystitis: extracorporeal shock wave lithotripsy
A
- type of therapeutic procedure
- Shock waves are used to break up stones
- Can be used on nonsurgical candidates of normal weight who have small, cholesterol based stones
- Nursing Actions:
- Instruct and assist client to lay on fluid filled pad for delivery of shock waves
- Administer analgesia
- Client Edu:
- Inform client that several procedures can be required to break up all stones
- Client may have pain intraprocedure due to gallbladder spasm of removal of stones
13
Q
cholecystectomy: what is it?
A
- Removal of gallbladder w/ laparoscopic, minimally invasive, or open approach
- Client can be discharged in 24 hr if laparoscopic approach used
- Open approach requires hospitalization for 1-2 days
14
Q
laparoscopic approach to a cholecystectomy
A
- nurse should provide immediate post op care
- client edu:
- ambulate frequently to minimize free air pain
- Monitor incision for evidence of infection or wound dehiscence
- Pain control
- Report indications of bile leak: pain, vomiting, abdominal distention
- Resume activity gradually
- Resume pre op diet
15
Q
minimially invasive approach to a cholecystectomy
A
- natural orifice transluminal endoscopic approach
- Explain to the client that this surgical procedure is performed thru entry of the mouth, vagina, or rectum
- Eliminates visible incisions and dec risk of complications
16
Q
open approach to a cholecystectomy
A
- Jackson Pratt drain placed in gallbladder bed or a T tube in the common bile duct
- Less common but clients can have T tube placed in common bile duct to drain bile if there were intraoperative complications involving the bile duct
- client edu:
- Resume activity gradually
- Avoid lifting for 4-6 wks
- Begin w/ clear liquids and advance to solid foods as peristalsis resumes
- Report sudden inc in drainage, foul odor, pain, fever, or jaundice
- Take showers instead of baths until drainage tube removed
- Color of stools should return to brown in about a week
- Diarrhea is common
- Resume activity gradually
17
Q
how to care for the drainage tube after a cholecystectomy
A
- Clients w/ JP drain placed intraoperatively to prevent accumulation of fluid in gallbladder bed
- Monitor and record drainage
- Initially will be serosanguinous stained with green brown bile
- Abx often prescribed to dec risk for infection
18
Q
how to care for a T tube after a cholecystectomy
A
- Report absence of drainage w/ manifestations of nausea and pain (indicates obstruction)
- Inspect skin for infection or bile leakage
- If prescribed, elevate T tube above level of abdomen to prevent total loss of bile
- Monitor and record color/amount of drainage
- Clamp tube 1 hour before and after meals to provide bile necessary for food digestion
- Assess stools for color
- Will be clay colored until biliary flow is re-established
- Monitor for bile peritonitis–>pain, fever, jaundice
- Monitor response to food
- Expect removal in 1-3 wks
19
Q
dietary counseling after a cholecystectomy
A
- Encourage low fat diet: reduce dairy, avoid fried foods/chocolate/nuts/gravies
- Inc tolerance if small frequent meals
- Avoid gas forming foods: beans, cabbage, cauliflower, broccoli
- Promote weight reduction
- Take fat soluble vitamins or bile salts as prescribed to enhance absorption and aid w/ digestion
20
Q
cholelithiasis/cystitis: list the possible complications
A
- obstruction of bile duct
- bile peritonitis
- postcholecystectomy syndrome
21
Q
cholelithiasis/cystits: complication of obstruction of the bile duct
A
- Can cause ischemia, gangrene, and rupture of gallbladder wall
- Rupture of gallbladder can cause a local abscess or peritonitis (rigid, board like abdomen, guarding) which requires a surgical intervention and administration of broad spectrum abx
22
Q
cholelithiasis/cystitis: complication of bile peritonitis
A
- Can occur if adequate amounts of bile are not drained from surgical site
- Rare but potentially fatal complication
- Nursing Actions:
- Monitor for pain, fever, jaundice
23
Q
cholelithiasis/cystitis: complication of postcholecystectomy syndrome
A
- Manifestations of gallbladder dz can continue after surgery
- Client will report findings similar to those experienced prior to surgery related to pain and nausea
- Manifestations can recur immediately or months later
- Nursing Actions:
- Assess pain characteristics and other reported findings
- Instruct client on the need for possible further diagnostic eval
