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Nursing 272: Final Semester > Unit 3: Cholecystitis > Flashcards

Unit 3: Cholecystitis Flashcards

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1
Q

Biliary System

A
  • includes the gallbladder and bile ducts
  • the cystic duct (from the gallbladder) and the hepatic duct (from the liver) join to form the common bile duct
  • primary function: transport bile from the liver, where it is produced, to the gallbladder, where it is stored, and then to the duodenum, where it aids in the digestion of fats
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2
Q

Primary Function of the Biliary System

A

transport bile from the liver (where it is produced), to the gallbladder (where it is stored), and then to the duodenum (aids in the digestion of fats)

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3
Q

Bile

A
  • digestive enzyme

- helps break down fats

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4
Q

When does biliary Disease occur?

A

when the gallbladder or ducts become inflamed, infected, or cancerous, impairing the ability of the gallbladder to function normally

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5
Q

Cholecystitis

A

inflammation of the gallbladder caused by an obstruction of bile flow

  • calculous cholecystitis (presence of gallstones)
  • acalculous cholecystitis (without stones)
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6
Q

Gallstones

A

(cholelithiasis)
hard deposits formed from bile contents that often cause obstruction of ducts in and around the gallbladder
-vary in size
-can have single or multiple stones

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7
Q

S/S associated w/ Gallstones: Five F’s

A
  • Fair
  • Fat
  • Female
  • Fertile
  • Over Forty years of age
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8
Q

Risk Factors For Gallstones

A
  • obesity
  • rapid weight loss
  • weight-loss surgery
  • eating large amounts of food with saturated fats
  • pregnancy (b/c of elevated progesterone)
  • genetics
  • medications (estrogen, octreotide, and cholesterol-lowering meds)
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9
Q

3 Categories of Gallstones

A
  • Cholesterol stones (most common)
  • Pigmented (formed from excess Bilirubin)
  • Mixed (combination of both types)
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10
Q

Acalculous Cholecystitis

A
  • w/o stones
  • associated with biliary stasis
  • there is a slowing or stopping of the flow of bile either from decreased contractility of the gallbladder or spasms in the sphincter of Oddi
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11
Q

Clinical Manifestations of Acute Cholecystitis

A

-ranges from no physical findings to pain and tenderness in the RUQ, sometimes w/ rebound tenderness or guarding, fever, and tachycardia

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12
Q

The Pain associated with Cholecystitis is d/t?

A

the release of cholecystokinin, which causes the gallbladder to contract

  • pain described as colicky, which is intermittent and radiating to the back, and is r/t the movement of the gallstones through the bile ducts as the bile flows
  • there are several small valves in the ducts, and the colicky pain is due to the movement of stones through these areas
  • radiation to the back is r/t the innervations of the gallbladder
  • have palpable fullness in RUQ, and exhibit a positive Murphy’s sign
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13
Q

Murphy’s Sign

A

pain on palpation of the RUQ upon deep inspiration

  • examiners fingers are placed on the RUQ of the abdomen, and then the examiner gently presses down while asking the patient to take a deep breath
  • test is positive if the patient has pain upon deep inspiration
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14
Q

Causes of Acalculous Cholecystitis

A
  • Abdominal surgery
  • Severe trauma
  • Long-term IV nutrition (> 1 month)
  • Prolonged fasting
  • Sickle cell disease
  • Diabetes Mellitus
  • Endotoxin
  • AIDS
  • Salmonella infection
  • Cytomegalovirus
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15
Q

Diagnostic Tests

A

-Abdominal X-ray
-Abdominal Ultrasonography
-Computed tomography (CT)
-Hepatobiliary iminodiacetic acid (HIDA) scan
-Endoscopic Retrograde Cholangiopancreatography (ERCP)
-Cholecystography
-Cholangiogram
>Others: CBC and liver function tests

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16
Q

Diagnostic Test: Abdominal X-ray

A

used to detect calcified gallstones

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17
Q

Diagnostic Test: Abdominal Ultrasonography

A
  • noninvasive
  • determines presence of gallstones and acute cholecystitis
  • a thickened gallbladder is indicative of cholecystitis
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18
Q

Diagnostic Test: CT scan

A
  • visualizes entire abdomen

- can detect presence of gallstones

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19
Q

Hepatobiliary Iminodiacetic Acid (HIDA) Scan

A
  • nuclear medicine scan
  • uses a radioactive tracer to study the production and flow of bile, visualizing the liver, gallbladder, bile ducts, and small intestine
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20
Q

Endoscopic Retrograde Cholangiopancreatography (ERCP)

A
  • allows visualization of the common bile duct where gallstones can be removed
  • a percutaneous drain can be placed in patients with acalculous cholecystitis who are a high operative risk
  • NPO night before procedure; can take their cardiac and BP meds the morning of w/ a small amount of water
  • sedated; need to have someone drive them home
  • after procedure, goes to PACU to allow time for recovery from the sedation
  • nurse observes the patient for a potential systemic inflammatory response syndrome (SIRS) caused by the manipulation of the bile ducts and potential bacterial translocation
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21
Q

Cholecystography

A
  • rarely used
  • radiographic test of the gallbladder after the patient orally takes radiopaque dye, which collects in the gallbladder and is excreted by the liver
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22
Q

Cholangiogram

A
  • used in the OR to image the biliary tree

- a radiopaque dye, usually containing iodine, is injected intravenously, which outlines the bile ducts and gallstones

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23
Q

Findings Associated with CBC and Liver Function Tests

A
  • Elevated WBC due to inflammation
  • Elevated liver enzymes: AST, ALT, Lactate dehydrogenase (LDH), Alkaline phosphate (ALP) and Bilirubin (b/c of blockage of bile flow in bile ducts)
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24
Q

Treatment of Gallstones

A

extracorporeal shock wave therapy or lithotripsy to dissolve gallstones

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25
Q

Extracorporeal Shock Wave Therapy

A

patients sit in a tub of water, and high-energy sound shock waves were directed through the water toward the stones to break them up into smaller pieces that would then pass through the bile duct

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26
Q

Lithotripsy

A
  • used for treatment of small gallstones

- helps dissolve gallstones

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27
Q

Treatment of Acute Cholecystitis

A
  • NPO; to prevent release of cholecystokinin, which is activated when eating and causes the gallbladder to contract and release bile, which leads to pain
  • Narcotics (meperidine [Demerol]) used for severe pain management
  • Acetaminophen or nonsteroidal medication (ibuprofen) used for less severe pain
  • Morphine contraindicated
  • IV hydration
  • Correction of electrolyte and fluid imbalances
  • Pain management
  • IV antibiotics as indicated
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28
Q

Oral Agents Used to Dissolve Gallstones

A

> Ursodiol
Actigall
Chenodiol
-natural bile acids; provided to reduce the size and number of gallstones
-drawback: need to take for up to 2 years; expensive; if patient stops, the stones reappear
-patients may be noncompliant b/c of prolonged treatment

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29
Q

Foods to Avoid In the Diet

A

several foods contribute to the formation of gallstones and should be avoided
-Fatty foods; fried foods, ice cream, dairy products, red meats, and heavy alcohol

30
Q

Foods to have In the Diet

A

foods low in saturated fats

-rice, potatoes, pasta, yogurt, fruits, lean meat, and whole grains

31
Q

Surgical Management For Cholecystitis

A
  • several options
  • dependent on the presentation of the patient and severity of manifestations
  • standard: laparoscopic cholecystectomy
  • open surgical procedure indicated if perforated gallbladder or peritonitis
32
Q

Standard Surgical Treatment

A

laparoscopic cholecystectomy

33
Q

When is A Open Cholecystectomy Indicated?

A
  • if patient has complication such as a perforated gallbladder or peritonitis
  • has a hx of previous abdominal surgeries
  • morbidly obese
34
Q

T Tube/ Biliary drainage tube

A

If stones are present in the common bile duct, the surgeon may place a T tube or biliary drainage tub, into the common bile duct to monitor bile drainage

  • tube exits the patient’s abdomen through the skin and is connected to a closed drainage system
  • may stay in place for up to 2 weeks after surgery
  • bile output should not exceed 500 mL in the first 24 hours
35
Q

Laparoscopic Cholecystectomy

A
  • uses several small incisions in the abdominal cavity
  • carbon dioxide gas is inserted to create space in the abdomen, and the surgical instruments and a laparoscope are placed through the incisions to remove the gallbladder
  • involves general anesthesia
  • can be done outpatient, or require hospitalization overnight
36
Q

Postoperative Period For Laparoscopic Cholecystectomy

A
  • Recovers from anesthesia in PACU
  • nurse monitors vital signs, pain, neurological status, N/V, and surgical site for distention, bleeding, or bruising
  • once awake and following commands, clear liquids are given slowly in small amounts to prevent N/V
  • after first 12 hours of liquids and no nausea, vomiting, or abdominal cramping, patients can gradually introduce small amounts of solid foods and maintain a low-fat diet
37
Q

Discharge Instructions for Laparoscopic Cholecystectomy

A
  • incision care; keep Band-Aid or dressing on for first 24 hours then remove
  • recognizing S/S of infections
  • signs of jaundice
  • pain medication instruction
  • constipation prevention
  • activity level; encourage walking and normal activity within a week, such as driving, working, and light lifting of less than 10 lbs.
  • no driving while taking narcotics
  • ok to shower after the first 48 hours; do not let the water pressure flow directly on the incision; increases risk of infection
  • do not soak in a tub, pool, or hot tube for up to 1 week
38
Q

Pain After Laparoscopic Cholecystectomy

A

can occur at the incisions and sometimes in one or both of the shoulders b/c of irritation of the diaphragm from the carbon dioxide gas given during surgery

39
Q

Post-Operative Care for T-Tube

A
  • assessment of the characteristics of the drainage (color, consistency, and amount)
  • routine emptying of he contents
  • skin care
  • routine flushing w/ appropriate preservative-free solution as ordered
  • patient teaching: information about care, biliary drainage, S/S of obstruction, color of urine and stool (if bile is being drained outside of the body), and infection
40
Q

Open Cholecystectomy

A
  • removal of the gallbladder through an open incision in the abdomen
  • general anesthesia
41
Q

Postoperative Care After Open Cholecystecomy

A
  • monitoring vital signs, pain, neurological status, and the abdomen for S/S of distention, bleeding, or bruising
  • once passing flatus, clear liquids are introduced, and diet is advanced to regular if no N/V
  • pain management via patient-controlled analgesia or PRN
  • pulmonary interventions to encourage lung expansion
  • coughing and deep breathing
  • walking encouraged
42
Q

Discharge Teaching For After an Open Cholecystectomy

A
  • S/S of infection
  • Prevention of constipation
  • Low-fat diet
  • Activity level
  • Routine care and teaching of T-tube management if present
43
Q

Discharge Teaching For After an Open Cholecystectomy

A
  • S/S of infection
  • Prevention of constipation
  • Low-fat diet
  • Activity level
  • Routine care and teaching of T-tube management if present
44
Q

Nursing Management: Assessment and Analysis

A
  • most common symptom of acute cholecystitis is abdominal pain
  • colicky pain, which is intermittent and radiating to the back
  • RUQ tenderness, fever, and elevated HR
  • positive Murphy’s sign; elicited during deep palpation of the abdomen; pain occurs when the inflamed gallbladder touches the peritoneum during deep inspiration; not unusual for pts to quickly hold their breath or stop breathing when they experience pain from this test
  • elevated liver enzymes, bilirubin, and WBC b/c of obstruction and inflammation
45
Q

Nursing Diagnoses

A
  • Acute pain r/t obstruction and edema r/t gallstones
  • Fluid volume deficit r/t nausea, vomiting, and increased insensible fluid loss
  • Imbalanced nutrition, less than body requirements r/t nausea and vomiting
  • Knowledge deficit regarding condition, prognosis, treatment regimen, self-care, and discharge needs
46
Q

Nursing Assessments

A
  • Vital Signs
  • Serum Electrolytes
  • Serum WBC
  • Liver enzymes, Bilirubin
  • Skin Turgor
  • Pain
  • Abdominal assessment: distention, bowel sounds, Murphy’s sign
  • Stool
  • Daily Weight
  • Intake and Output
  • Nutritional intake
47
Q

Assessment: Vital Signs

A
  • fever and tachycardia may represent inflammation d/t gallstones
  • elevated respiratory rate r/t anxiety and pain
  • respiratory rate shallow and rapid b/c of pain
  • BP low as a result of dehydration/inflammatory response
48
Q

Assessment: Serum Electrolytes

A
  • measure imbalanced electrolytes d/t dehydration and lack of oral intake
  • include BUN and Creatinine (elevated)
  • with nasogastric tube (NG) suctioning, potassium monitored
49
Q

Assessment: WBC

A

inflammation leads to an elevated WBC count

50
Q

Assessment: Liver Enzymes and Bilirubin

A

Liver enzymes (AST, ALT, LDH, and ALP) and bilirubin are elevated b/c of blockage of bile flow in the bile ducts

51
Q

Assessment: Skin turgor

A

decreased = dehydration

52
Q

Assessment: Pain (onset, duration, exacerbating and relief factors)

A
  • can be intermittent and colicky
  • can be severe epigastric and in the RUQ w/ radiation to the back, mid-shoulder/scapula, or in the chest
  • onset is fast; within 1 hour of eating a high-fat meal
  • common at night
53
Q

Assessment: Abdominal distention, bowel sounds, Murphy’s sign

A

palpation may reveal rebound tenderness, muscle guarding, or rigid abdominal muscles d/t pain

54
Q

Assessment: Stool

A
  • Steatorrhea; presence of excess fat in stool or oily stools
  • clay-colored stools d/t blockage of bile flow
55
Q

Assessment: Daily weight

A

info in regard to fluid gains or losses

56
Q

Assessment: Intake and Output

A

provide data about fluid volume status and prevent dehydration

57
Q

Assessment: Nutritional Intake

A

determines diet hx, fat intake, foods that can contribute to symptoms

58
Q

Nursing Actions

A
  • Maintain NPO
  • Administer ordered antibiotics
  • Administer ordered bile acid reducers
  • Administer analgesics as ordered
  • Administer antiemetics as ordered
  • Promote bedrest in Semi-fowlers position
  • NG tube to low suction
59
Q

Actions: Maintain NPO

A

prevents gallbladder contraction that releases bile to break down nutrients; these contractions cause pain b/c of the inflamed gallbladder

60
Q

Actions: Administer ordered antibiotics

A

short course of antibiotics may be given to reduce inflammation and treat infection

61
Q

Actions: Administer ordered bile acid reducers

A

bile acid reducers help dissolve gallstones

62
Q

Actions: Administer analgesics as ordered

A
  • decrease symptoms of pain

- avoid morphine d/t spasm of the sphincter of Oddi

63
Q

Actions: Administer antiemetic as ordered

A

decrease symptoms of N/V, which may occur for a prolonged time d/t abdominal pain and obstruction

64
Q

Actions: Promote bedrest in semi-Fowler’s position

A
  • avoid lying flat; makes pain worse; stretches the abdominal muscles when supine
  • repositioning helps alleviate abdominal pain and pressure
65
Q

Actions: NG tube to low suction (intermittent or continuous based on type of tube)

A

used to decompress the stomach and remove gastric secretions

66
Q

Nursing Teachings

A
  • Postoperative instructions
  • T-tube management
  • Avoid diet high in saturated fats
  • Disease clinical manifestations, progression, diagnostic procedures, and interventions
67
Q

Teaching: Avoid a diet high in saturated fats

A
  • obtain diet hx
  • bile breaks down fats; thus, a diet high in fat requires activation of bile for breakdown and increases pain
  • stress small, frequent meals
68
Q

Evaluating Care Outcomes

A
  • Cholecystitis is a manageable disease process
  • educate patients about the disease and manifestations; help develop a plan for prevention
  • pain management and medical and/or surgical management
  • Recovery indicators: absence of pain, vital signs and fluid status WNL, normalizing liver enzymes and WBC count
69
Q 
Connection Check: The nurse recognizes which as risk factors for cholecystitis?
A. Obesity
B. Male
C. Female
D. African American Descent
E. European Descent
A

A. Obesity
C. Female
E. European Descent

70
Q 
Connection Check: The nurse correlates which clinical manifestation with cholecystitis?
A. Retroperitoneal pain
B. Absence of bowel sounds
C. Diarrhea
D. RUQ pain
A

D. RUQ pain

71
Q 
Connection Check: The nurse should question the administration of which medication in the patient admitted with cholecystitis?
A. Acetaminophen
B. Demerol
C. Ibuprofen 
D. Morphine
A

D. Morhpine

>usually contraindicated for pain management b/c it can cause the sphincter of Oddi to spasm, which results in pain

Nursing 272: Final Semester (79 decks)

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