GERDS/PUD/Gall bladder disease Flashcards
occurs when the mucosal barrier breaks down and an inflammatory response occurs within the esophagus because of the acid content of the reflux matter
Gastroesophageal Reflux Disease
replacement of the squamous cell epithelium of the lower esophagus with new tissue that is more resistant to acid but is considered premalignant.
Chronic gastroesophageal reflux can lead to::
Barrett’s epithelium
narrowing of the esophageal opening. this may lead to progressive difficulty in swallowing.
Esophageal stricture
A decrease of the lower esophageal sphincter tone.
-delayed gastric emptying.
-older adults experience impaired esophageal peristalsis
Conditions that elevate intra-abdominal pressure:
ie. obesity, pregnancy, heavy lifting, hiatal hernias, wearing tight belts or girdles
Factors that increase chances for GERDS
Foods/beverages Smoking Medications Hormones Peppermint, spearmint NG tube placement
Factors contributing to decreased lower esophageal sphincter pressure: GERD
Heartburn (dyspepsia) Regurgitation Eructation (belching) Water brash Nocturnal cough Flatulence Dysphagia (difficulty swallowing) Chest pain Odynophagia (painful swallowing) Chronic cough-at night Nausea
Physical Assessment/Clinical Manifestations
Hx and presents of predisposing factors
24 hr. ambulatory esophageal pH monitoring
Esophagogastroduodenoscopy (EGD)
Esophageal manometry (pressure, look at esoph.spincter; tight or loose)
Barium Swallow test
Diagnosing GERDS
Relief of symptoms
Treatment of Esophagitis
Prevention of Complications such as strictures
Purpose of nonsurgical management of GERDS
Nutrition Therapy
Lifestyle Changes
Drug Therapy
Patient and Family Teaching for GERDS
-Limit or eliminate foods that decrease LES pressure
-Drink fluids with meals; helps break it up
-Mastication and eat more frequent meals; 6 sm. meals a day, more you chew, quicker digestion
[Fats are slower to digest, carbs are the quickest (glucose)] (carbs, proteins, then fats)
-Avoid eating for at least 3 hours before going to bed. [slower to digest, produces more acid, increase chance of reflux]
-Avoid alcohol and tobacco (nicotine);
Nutritional therapy; relieve symptoms for patients with mild GERDS
- Elevate the head of the bed 6 to 12 inches. Never sleep on flat bed!! Sleep right side-lying position (no pressure on stomach)
- Lose weight if overweight.
- Avoid wearin constrictive clothing.
- Avoid heavy lifting, straining, and working in a bent-over position.
- Avoid drugs that lower the LES pressure such as oral contraceptives-, anti-cholinergic agents, sedatives, NSAIDS, calcium channel blockers
Lifestyle changes for GERDS
Antacids
Histamine 2 receptor antagonists
Proton Pump inhibitors
Pharmacology regime for GERDS management
- inhibit gastric acid secretion
- accelerate gastric emptying
- protect the gastric mucosa
GERD: These drugs have one or more of the following functions: Antacids Histamine 2 receptor antagonists Proton Pump Inhibitors
Promote the gastric mucosal defense mechanisms by stimulating the production and secretion of;
- Mucus; protective barrier against HCL
- Bicarbonate: Helps buffer acidic properties of HCL
- Prostaglandins: Prevents activation of proton pump!!
- Increases the LES pressure
Antacids: Mechanism of Action
GERDS
Commonly used Antacids include:
Aluminum Salts (constipation) and/or Magnesium Salts (diarrhea)
*Calcium salts (tums helps to produces kidney stones)
*Sodium bicarbonate; (Alkasetlzer)
*Alginates-Gaviscon; lowers pH, foam @ mouth, but baths the stomach.
Reduces heartburn symptoms
GERDS
- Use with caution with other medications due to the many drug interactions, and possible reduced drug absorption.
- Antacids may cause premature dissolving of entero-coated medications, resulting in stomach upset.
- Take antacids 1 hour before and/or two to three hours after ea. meal.
Antacids: Nursing Implications
GERDS
Block histamine (H2) at the receptors of acid producing parietal cells. -Thus the production of hydrogen ions is reduced, resulting in decreased production of HCL..
H2 Antagonists: Mechanism of Action
Zantac
GERDS
Take at least 1 hr before or after antacid.
Usually requires more than one dose a day.
Nursing Implications: h2 Antagonists; Gerds
Reduce acid secretion -Zantac (ranitidine) -Pepcid (famotidine) More potent, longer-acting drugs but produce fewer side effects than axid *Nizatidine (AXid) *cimetidine (Tagamet)
Histamine 2 receptor antagonists
GERDS
-too much, GERDS constant bleeding
-body will use pancreatic enzymes in duodenum instead of HCL acid
***Aluminum hydroxide (Alu-Cap, AlternaGEL)
Neutralize stomach acid secretions. Used for gastroesophageal reflux, peptic ulcers, gastritis.
Antacids GERDS
- esomeprazole (Nexium)
- lansopraxole (Pravacid)
- omeprazole (Priosec)
- pantoprazole (Protonix!!!)
- rabeprazole (AcipHex)
Blocks gastric acid secretions by inhibiting the hydrogen-potassium-ATPase pump in the stomach. Proton pump inhibitors are the drugs of choice for severe GERD!!***
Admin 30 min before breakfast and HS if BID.
Monitor liver values
Proton Pump Inhibitors; GERD
*cimetidine (Tagamet)
*ranitidine (Zantac)
*famotidine (Pepcid)
*nizatidine (Axid)
Blocks histamine, thus reducing the release of hydrogen ion secretion from the parietal cells, causing the pH to increase in the stomach.
**Used for acid-r/t disorders including gastroesophageal reflux and peptic ulcer disease.
H2-Receptor Blockers
Admin in 20-100 ml of solution over 15-30 mins. Do not mix with other drugs. Can cause dyshythmias and hypotension with rapid admin.
given po or iv
**Donot give antacid within 1 hr before or after admin of H2. receptor blocker.
Gi stimulate or prokinetic agent.
*metoclopramide (Reglan)
- Increase the tone of the lower esophageal sphincter and stomach contractions to move food through the stomach and sm. intestine.
- Used for gastroesophageal reflux and gastroparesis.
*Unlabeled use includes Hiccups.
Promotiliy Agents; GERDS
take 30 mins AC and HS.
Avoid using with intestinal obstruction or lactating.
EPS symptoms, diarrhea, possibe HTN crisis
Use cautiously and in reduced dosages in patients with renal disease. Dysrhythmias are common.
Axid (nizatidine); h2 receptor blocker
prevent the movement of hydrogen ions from the parietal cells resulting in the blocking of almost all gastric acid secretions.
*people have increased risk of hip fx.
*only give for 8 weeks;
Big Guns
Usually once/day but could be more often.
ie
prilosec (omeprazole)
Prevacid (lansoprazole) NG tube; can be given in granule form; can’t crush. in apple juice (NG) or apple sauce (po)
Nexium (esomeprazole); IV form
Protonix (pantoprazole); IV form *MOST commonly used
30 mins AC; can use for years
Gastric acid pump inhibitors (Proton Pump Inhibitors)
GERDS
Increases the strength of the esophageal peristalsis and increases the esophageal sphincter pressure. Most commonly used:
*Reglan (metoclopramide) Used at HS; severe nausea, EPS symptoms possible, anxiety
Increases gastric emptying
Take AC
*Not frequently prescribed because of neurological and/or psychotropic side effects.
Prokinetic Agents
GERD
Stretta Procedure or Endoluminal gastroplication
Endoscopic treatment for SEVERE GERDS
used laser beam, radiofreq. endoscope needles placed in gastroesophageal (closed to become more narrow)
Stretta Procedure; endoscopic treatment for severe GERDS; outpatient
sewing machine hooked to bottom of endoscope. Makes pleats and sews up hleps close LG sphincter
Endoluminal gastroplication Aka EndoCinch Suturing System
GERDS
Use of light or moderate sedation
Ambulatory care procedure
Short procedure (45 mins)
no ABX, and lower complication rate including fewer deaths
Advantages of Non-invasive Endoscopic Treatments
GERDS
- Clear liquid diet for 24 hrs after the procedure
- After the first day, soft diet such as custard, pureed vegetables, mashed potatoes, and applesauce.
- Avoid NSAIDS and ASA for 10 days; increases GI bleeding
- Continue drug therapy as prescribed, usually a proton pump inhibitor and use liquid meds if possible.
- No NG tube for at least 1 month; suction pressure too much/fragile
- Contact physician if the following occurs: chest or abdominal pain, bleeding, dysphagia, SOB, nausea or vomiting
Postoperative Patient Teaching
GERDS
A patient with gastroesophageal reflux disease (GERD) is prescribed pantoprazole (Protonix) 40 mg. What teaching will the nurse provide for this patient about the drug?
Do not crush the drug b/c it has a delayed release.
The patient with a long hx of osteoarthritis is at risk for developing Gastroesophageal reflux disease (GERD) if he or she:
Frequently take NSAIDS for pain; effects prostagladins, increase chance cause GERD.
A priority assessment of a patient having undergone an EGD is:
The patients gag reflex; b/c of anesthesia [EGD]. check gag before feeding, so they don’t choke
laparoscopic or conventional esophageal surgery
-Making upper part of stomach tighter and attach it to the diaphragm
Nissen fundoplication;
GERD
Know, before hand, what type of surgical approach is planned, abdominal or Laparoscopic.; thoracic cavity; collapse a lung requiring chest tubes.
Concern of infection**
**Explain the need for an NG tube that will be in place for several days for abdominal surgery. Not for Laparoscopic. Teach what surgery
**Oral intake will be started gradually after surgery.
Stomach inflammed and fragile. May end up irritating and might not go down.
**Prevention of respiratory complications-C&DB, incentive spirometer
***Availability of pain medications
Pre and post operative
Nursing Care
GERD
Obstructed nasogastric tube; NSS irrigate NG tube
- Atelectasis, pneumonia;
- Temporary dysphagia; nurse needs to observe 1st eating b/c stomach may have been wrapped too tight.
- Gas bloat syndrome; avoid gassy foods, [Hard to burp and get out] No drinking out of the straws. Gallbladder, laproscopic, too.
**Make them walk; drainage to go greenish/yellowish with in 8 hrs; if bloody (lots) problems; take VS might of perforated something.
Post Operative Assessments and Care following a Nissen Fundoplication;
GERD
Normal diet after 6 weeks of multiple, small meals
-Gradually explore tolerance to different foods
-Upright position when eating
-Avoid carbonated beverages and gas producing foods
-Avoid straining and prevent constipation
-Contact physician for fever above 101 degrees F, nausea, vomitting, or uncontrollable bloating or pain.
No Heavy Lifting!
Discharge Teaching for GERDS Post operative
A patient has undergone a Nissen Fundoplication. The nurse would know that the teaching episode was unsuccessful if the patient stated:
“I need to drink out of a straw for the next 6 weeks.”
No straws/ swallowing air!
A patient has Barretts Esophagus. Which patient assessment by the nurse requires consultation with the health care provider?
1st concern; Coughing when eating or drinking. [more concern for airway!]
results when the mucosal defenses become impaired and no longer protect the epithelium from the side effects of acid and pepsin.
Peptic Ulcer Disease (PUD)
*Gastric; antrum, part of stomach
*Duodenal;
*Stress; anywhere in stomach itself
H.pylori; increase chance of erosion
Prostadglands needed for nice fluffy mucous.
Three types of Peptic Ulcers
Cigarette smoking Family hx of PUD ***use of ASA***** H. pylori (lays in mucous of stomach) infection Low socioeconomic status Crowded, unsanitary living Unclean, food or water ****Use of NSAIDs;***** decrease production of prostaglandins Advanced age Hx of ulcer Concurrent drug use ***Glucocorticosteroids***
Risk Factors of Peptic Ulcer Disease
Refer to a syndrome characterized by the development of multiple, diffuse gastric lesions and ulcerations shortly after the onset of an acute illness, trauma or sepsis.
- *Common precipitating factors include:
- respiratory, renal, sepsis, or liver failure
Treatment
Same as the Gastric and Duodenal Ulcers
H2 receptor blockers and proton pump inhibitors; prevents stress ulcers.
Stress Ulcers
Data collection; alcohol intake, tobacco use, foods that precipitate or worsen symptoms.
Hx of the H. pylori infection
Review medications specifically corticosteroids, chemotherapy or NSAIDS.
Hx of radiation treatments
Hx. of gastric surgery
Nursing Assessment for PUD
Endoscopy (Gold Standard of dx) EGD
H-pylori screens include:
*urease breath test (see if presence of h. pylori); low cost
[drinks urea carbon 13. if breaks away into blood stream goes into lungs; increased amount of h.pylori)
*Serologic: lab test ELISA (enzyme-linked immunosorgent assay) serum blood
* Stool HpSA:
Other: Nuclear medicine GI Bleeding study (scan)
Can be used to dx. but to help with finalizing treatment
Diagnostic tests of PUD
Biggest reason people end up with H. Pylori PUD
b/c of bugs that eat away of lining in stomach
H. pylori PUD
Four primary goals for drug therapy:
- provide pain relief
- eradicate Helicobacter pylori infection
- Heal ulcerations
- prevent recurrence
Drug Therapy for PUD Primary goals
Histamine receptor antagonists
Proton Pump Inhibitors
Mucosal Protective Agents including Prostaglandin analogs (misoprostol)
Muscosal barrier fortifier; Carafate; pink pill stickds to side of ulcer
Antacids;
Drug Therapy for PUD
- Facilitate healing, eliminate symptoms, prevent complications
- Proton Pump inhibitor
- Metronidazole (Flagyl) and tetracycline; ABX
- Clarithromycin and amoxicilin; ABX
Treatment objectives for H-pylori infection
Will be test question*
Proton pump inhibitor, plus ABX (metronidazole [Flagyl} or amoxicillin, plus clarithromycin or
Histamine H2 Antagonist, clarithromycin or Flagyl plus tetracycline or ampicillin
***relieve symptoms and use 2 antibiotics!!!
Triple therapy for H. pylori infection PUD
Histamine Receptor Antagonist Proton pump inhibitor ABX; antibiotics Antacids; break through pain. Take antibiotics until all is gone, even if you feel better!
Medications PUD
Family/Patient Teaching
Meds Diet; if it upsets you, don't eat it. Smoking Stress Reduction Activity; don't over do it
Patient/Family Teaching PUD
Hemorrhage
Gastric Outlet Obstruction; scar tissue in sphincter b/c healed ulcer, food can’t get through
Perforation
Complications of a Peptic Ulcer
a result of ulceration and erosion into the blood vessels of the gastric mucosa. Major bleed.
Hemorrhage
- Occult blood in the stool; tarry stool, see it coming out.
- Obvious bleeding either in the stool or rectally
- Hematemesis; vomiting of blood
- Hematochezia; bright, frank, red blood coming out of rectum
- Weakness ; fast huge ulcer
- Orthostatic Hypotension
- Hypovolumic Shock
- Dizziness
- Fatigue
Hemorrhage signs and symptoms
First priority is to maintain airway breathing and circulation.
- Restoration and maintenance of adequate circulatory status
- Gastric intubation (NG)and saline lavage; room temp saline
- Administer antacids, IV H2 receptor antagonist IV and more importantly PPI’s; Saline increase volume, 0.09% NS helps raise Bp Na
Nursing Care of a client with an UGI hemorrhage
Therapeutic Endoscopy
-Intervention Radiologic Procedure for embolization used for massive bleeding or for those who are not surgical candidates.
Nursing care post operatively, monitor vital signs, pulse ox, and note any signs of bleeding.
Intervention Radiology: refrain from lifting more than 10 lbs., avoid strenuous activity for 72 hrs.
**Coffee ground emesis; slow bleed opp. for blood and acid to mix in stomach, curdles
Non-surgical therapy for UGI bleed
Minimally invasive surgery via Laparoscopy (type of endoscope) Repairs ulcers
- Traditional procedures:
- Vagotomy; cut some aphidicolin (vagus nerve) around stomach to decrease anticholinergic
- Subtotal gastrectomy; 1/2 total; 1/2 stomach
- Total Gastrectomy; all of stomach
- Pylorplasty; enlarge plylori sphincter, balloon
Surgical management for PUD
is an erosion of an ulcer through the mucosal wall. even worse than hemorrhage. ; knife through stomach
Perforation
Classic symptoms include:
- Sudden, sharp pain beginning in the midepigastric region and spreading over the entire abdomen. The amount of pain correlates with the amount and type of GI contents spilled.
- Rigid, board-like abdomen with rebound tenderness.
- Patient assumes a fetal position to decrease tension on the abdominal muscles.
- Absence of bowel sounds; b/c of hole
- Diaphoresis, Tachycardia; b/c of pain
- Rapid and shallow respirations;
- Pyrexia; increase temp
Perforation; classic symptomts
Immediate intervention is to restore homeostatis and minimize peritonitis
-IV fluids; NS
-Blood; take blood
-Electrolytes; need
-Antibiotics, IV
-Pain medication
-NPO with NG tube placement with suctioning; get out of stomach
-Fowler’s position or semi-Fowlers
(Chemical peritonitis; HCl in the peritoneal cavity)
**Monitor for clinical manifestations of septic shock such as fever, pain, tachycardia, lethargy or anxiety.
Nursing care of clients with UGI perforation
Results from edema surrounding the ulcer, muscle spasm or contraction of scar tissue. obstructs pyloric sphincter
- *Clinical Manifestations;
- sensations of abdominal bloating
- nausea and vomiting (may be projectile)
- electrolyte imbalances
- metabolic alkalosis; vomiting all acid
Pyloric (gastric outlet) Obstruction
NG to intermittent suction
- Observe for hypokalemia (as a result of vomiting), or metabolic alkalosis
- Administer IV fluids and electrolyte replacement
- Balloon catheter may be used to spread open the obstructed area
Nursing care for a client with an UGI obstruction
- Omental patch to close a perforation
- Vagotomy; is a division of the vagus nerve. (Partial, Truncal, or Selective)
Surgical Management UGI obstruction
- Is manifested by UGI tract ulceration which are caused by a gastrinoma or gastrin-secreting tumor of the pancreas, stomach, or intestines.
- The ulcerations are caused by high gastric acid secretions.
- Pain and Diarrhea is common
- Steatorrhea (excessive fat in the feces)
- Can result from an autosomal dominant disorder
- Treatment: suppress pharmacologically. Complete surgical resection-duodenum and/or pancreas. Also possible need for chemotherapy if tumor is cancerous.
Zollinger-Ellison Syndrome
Pain FVD Ineffective Breathing Patterns Sleep pattern disturbances Knowledge Deficits Altered Tissue Perfusion Risk for Injury Alter Nutrition: Less than Body Requirements
Nursing concerns when caring for patients with PUD
The nurse is caring for a patient with peptic ulcer disease. The patient vomits a large amount of undigested food after breakfast. Which intervention would the nurse expect the physician to order???
Insert a nasogastric NG tube to low intermittent suction.
The nurse is providing discharge teaching for a patient who has peptic ulcer disease caused by Helicobacter pylori infection. Which statement by the patient indicates that additional teaching is needed?
I will take my medication every day until my heartburn is gone.
The nurse is caring for a patient with a history of HF and GERD. The client tells the nurse about taking 2 teaspoons of sodium bicarbonate every night before to bed to prevent heartburn. Which is the nurse’s best response??
I will let your doctor know so a saer antacid can be prescribed for you.
Pre-op;
- ensure hydration
- NG inserted and connected before surgery,
- educated client about pain medications, coughing and
- deep breathing exercises, incentive spirometer, and need to NG tube
- teach client about possible hyperalimination after surgery
Nursing Care for clients undergoing Gastric Surgery
Dressings: immediately post op may have serosanguineous drainage due to drains in the abdominal incision
- NG tube: if tube stops draining do not try to adjust the position of the tube, call MD
- NG tube drainage should look like…..
- Implement actions to prevent thrombus and embolus formation
- Assess for return of peristalsis
Post operative care of clients undergoing gastric surgery
- Usually a complication when the pylorus is bypassed and as a result of an extensive resection.
- Due to rapid dumping of large amounts of food and fluids into the intestine, causing rapid distention of the small intestines
Dumping Syndrome
Nausea, vomiting (occasional)
epigastric fullness and distention
abdominal cramping and diarrhea (explosive)
dyspepsia (indigestion)
GI signs and symptoms of dumping syndrome
Symptoms are r/t decreased circulating blood volume
- sensation of weakness, syncope and vertigo
- orthostatic hypotension
- pallor or flushing
- diaphoresis
- cardiac palpitations, tachycardia
Vasomotor S&S of Dumping Syndrome
Diet
Activity
Medications
Treatment of Dumping Syndrome
- Nutrition: When client able to eat, small meals forever, eat easily digested foods and must be taught to chew foods thoroughly
- Diet supplements and/or blenderized foods; possible jejunostomy tube or TPN. Vit B12 injections monthly
- Pain meds availability
- Potential long term problems of Dumping Syndrome &/or Malabsorption of fats.
Discharge teaching after Total Gastrectomy
The nurse is caring for a patient who has recently undergone a partial gastrectomy. The patient asks the nurse which foods would be best for him to have for breakfast. Which menu items does the nurse recommend for the patient? Choose all that apply:
Plain bagel with margarine or butter
Poached eggs and a slice of bacon
The nurse is caring for a patient with advanced gastric cancer who is scheduled for palliative surgery to relieve gastric outlet obstruction. The patient asks the nurse why he should bother having the surgery, because he will not be cured. Which is the nurse’s best response?
It will relieve the obstruction so you will be more comfortable and able to eat again.
The nurse is caring for a patient who will undergo a gastrectomy the following day. Which interventions are included in the postoperative plan of care for the patient??? (more than one)
Monitor and record accurate intake and output.
Remind the patient daily to use patient-controlled analgesia (PCA) before the pain becomes severe.
Protective process May result from injury, infection Stimulates healing Prevent further damages Prevent progressive deterioration
Inflammation
*Brings fluid, dissolved substances, blood cells to tissues where invasion or damage occurred.
-Nonspecific:
Invader neutralized; healing initiated
Phagocytosis
Adequate nutrition essential
Adapted mechanim
Adaptive response of injury or illness (inflammation)
Pain
Swelling
Redness
Heat
Impaired function of the part if the injury is severe.
Common words with the suffix “it is” describe an inflam. process
Characteristics of Inflammation
History
Risk
Client self-report that suggests inflammation
Assessment of Inflammation
Signs and symptoms vary according to area
Widespread inflammation; diverse symptoms
Physical Assessment inflammation
****Erythroctye sedimentation rate (ESR) Normal male=0-15 mm/h Normal female=0-25 mm/h ***C-reactive protein (CRP) ** Others -WBC with differential Routine chemistry panels
Diagnostic Tests to detect inflammation
Cholecystitis: Inflammation of the GB
Cholelithiasis: the presence of calculi in the GB
Biliary Conditions (inflammation)
Acute infection of the GB causing pain, tenderness, and rigidity of the RUQ, associated with N & V and fever
Cholecystitis
a GB stone obstructs bile outflow
- bile in the GB initiates autolysis and edema
- blood supply to the GB is compromised
- Gangrene with perforation can result
Calculous cholecystitis
Gallstones usually form in the GB from the solid constituents of bile
- increasingly prevalent after the age of 40
- pathophysiology: 2 types
- pigment stones
- cholesterol stones (majority)
Cholelithiasis
Clinical Manifestations:
- Gallstones may be silent
- Symptoms may relate to diseases of the GB itself or due to obstruction of bile flow by a gallstone
- Epigastric distress, fullness, abdominal distention, and vague pain in RUQ
Gallstones within the Gallbladder and Obstructing the Common Bile and Cystic Ducts
If gallstone obstructs the cystic duct, the GB becomes distended & infected
- Biliary colic: excruciating RUQ pain that radiates to the back or right shoulder, associated with N & V; Lasts 1-5 hrs, decreased bowel sounds, follows after a high fat meal
- Meperidine usually given (Avoid use of Morphine: causes spasms at sphincter of Oddi)
Pain & Biliary Colic
Occurs in a small percentage of patients with GB disease; obstruction of the common bile duct
- The bile is absorbed by the blood, giving the skin & mucous membranes a yellow color; usually assoc with itching.
- Changes in urine and stool color
- The excretion of bile pighments by the kidney give urine a very dark color
- The feces, no longer colored with bile pigments are grayish, clay colored.
- Vitamin deficiency
- Obstruction of bile flow interferes with the absorption of fat soluble vitamins (A, D, E & K)
Pain & Biliary Colic
Abdominal X Ray Ultrasonography: procedure of choice Radionuclide Imaging (Cholescintography) AKA: Gallbladder scan Endoscopic Retrograde Cholangiopancreatogram (ERCP)
Diagnostic Evaluation GB
Supportive & Dietary Management
Pharmacotherapy
CDCA-Chenix
UDCA-Ursodrol
Non-Surgical Management GB
Nonsurgical Removal of Gallstones
- Extracorporeal Shock-Wave Lithotripsy
- Endoscopic Removal of Gallstones (ERCP)
non-Surgical Management GB
*Foods high in cholesterol
-Dairy products (whole milk, ice cream, butter, cream, cheese)
Other Foods:
*Fried, fatty foods
*Rich pastries
*Gravies, nuts
Gas forming vegetables: cabbage, onions, broccoli, cauliflower, sauerkraut, radishes, cucumbers, beans
Foods for Patients with Cholecystitis or Cholelithiasis to Avoid
- Pre-operative Period
- X ray studies of GB, Chest X ray, ECG, LFT’s
- Vit K if Prothrombin levels are low
- Instruction in importance of C & DB, use of IS, spinting of incision, use of NG suction, & drains post op
Surgical Management GB
Cholecystectomy: the GB is removed after the cystic duct and artery are ligated.
- Laparoscopic cholecystectomy
www. laparoscopy.com - Choledochostomy: an incision is made in the CBD to retrieve stones
- Surgical Cholecystostomy
Surgical Procedures: GB
Several small incisions made; trocar catheter inserted
Pneumoperitoneum: CO2 gas instilled into abdomen to aid in visualization. Gas is removed upon exiting.
-Post -op: Increased incidence of nausea and vomiting
-NO straws, carbonated beverages; antiemetics
-Much shorter recovery time
Laparoscopic Surgery; GB
Assessment
Preadmission testing
Assessment should be focused on respiratory status
Smoking hx or other respiratory problems assessed
Nutritional status evaluated
Nursing Process GB
- Pain & Discomfort R/t surgical incision
- Impaired gas exchange r/t high abdominal surgical incision (traditional cholecystectomy)
- Impaired skin integrity r/t altered biliary drainage (use of a T tube if stones found in CBD)
- Altered nutrition r/t inadequate bile secretion
Nursing Diagnosis GB
- Used if any surgical manipulation of CBD is done
- Provides for drainage of bile while inflammation of CBD decreases
- I&O: Teach client how to empty
- Surgeon will give order to clamp T tube (unclamp for GI distress)
- Usually removed in office
T Tube
T-tube placement in th ecommon bile duct. Bile fluid flows with gravity into a drainage collection device below the level of the common bile duct.
- Low Fowler’s position after recovered from anesthesia
- IV fluids, NG suction
- Advance diet after bowel recovery
- Pain relief: subcostal incision: use of splinting, abdominal binder
- Respiratory status: pneumonia main complication
-Skin Care/Biliary Drainage
*Penrose drain: dressing changes as ordered
T-tube: connected to drainage bag: measure & record *drainage.
*Tube is clamped; if tolerated, then tube is removed.
-Nutritional status: low fat, high CHO
Nursing Interventions GB
- Patient may be discharge with drains
- Report following symptoms to physician: jaundice, dark urine, pale colored stools, pruritis, severe pain
- Complications; bleeding, perforation
Discharge teaching; GB
