Unit 3: Cholecystitis Flashcards
Biliary System
- 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
Primary Function of the Biliary System
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)
Bile
- digestive enzyme
- helps break down fats
When does biliary Disease occur?
when the gallbladder or ducts become inflamed, infected, or cancerous, impairing the ability of the gallbladder to function normally
Cholecystitis
inflammation of the gallbladder caused by an obstruction of bile flow
- calculous cholecystitis (presence of gallstones)
- acalculous cholecystitis (without stones)
Gallstones
(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
S/S associated w/ Gallstones: Five F’s
- Fair
- Fat
- Female
- Fertile
- Over Forty years of age
Risk Factors For Gallstones
- 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)
3 Categories of Gallstones
- Cholesterol stones (most common)
- Pigmented (formed from excess Bilirubin)
- Mixed (combination of both types)
Acalculous Cholecystitis
- 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
Clinical Manifestations of Acute Cholecystitis
-ranges from no physical findings to pain and tenderness in the RUQ, sometimes w/ rebound tenderness or guarding, fever, and tachycardia
The Pain associated with Cholecystitis is d/t?
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
Murphy’s Sign
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
Causes of Acalculous Cholecystitis
- Abdominal surgery
- Severe trauma
- Long-term IV nutrition (> 1 month)
- Prolonged fasting
- Sickle cell disease
- Diabetes Mellitus
- Endotoxin
- AIDS
- Salmonella infection
- Cytomegalovirus
Diagnostic Tests
-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
Diagnostic Test: Abdominal X-ray
used to detect calcified gallstones
Diagnostic Test: Abdominal Ultrasonography
- noninvasive
- determines presence of gallstones and acute cholecystitis
- a thickened gallbladder is indicative of cholecystitis
Diagnostic Test: CT scan
- visualizes entire abdomen
- can detect presence of gallstones
Hepatobiliary Iminodiacetic Acid (HIDA) Scan
- nuclear medicine scan
- uses a radioactive tracer to study the production and flow of bile, visualizing the liver, gallbladder, bile ducts, and small intestine
Endoscopic Retrograde Cholangiopancreatography (ERCP)
- 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
Cholecystography
- 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
Cholangiogram
- 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
Findings Associated with CBC and Liver Function Tests
- 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)
Treatment of Gallstones
extracorporeal shock wave therapy or lithotripsy to dissolve gallstones
Extracorporeal Shock Wave Therapy
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
Lithotripsy
- used for treatment of small gallstones
- helps dissolve gallstones
Treatment of Acute Cholecystitis
- 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
Oral Agents Used to Dissolve Gallstones
> 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
Foods to Avoid In the Diet
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
Foods to have In the Diet
foods low in saturated fats
-rice, potatoes, pasta, yogurt, fruits, lean meat, and whole grains
Surgical Management For Cholecystitis
- 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
Standard Surgical Treatment
laparoscopic cholecystectomy
When is A Open Cholecystectomy Indicated?
- if patient has complication such as a perforated gallbladder or peritonitis
- has a hx of previous abdominal surgeries
- morbidly obese
T Tube/ Biliary drainage tube
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
Laparoscopic Cholecystectomy
- 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
Postoperative Period For Laparoscopic Cholecystectomy
- 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
Discharge Instructions for Laparoscopic Cholecystectomy
- 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
Pain After Laparoscopic Cholecystectomy
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
Post-Operative Care for T-Tube
- 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
Open Cholecystectomy
- removal of the gallbladder through an open incision in the abdomen
- general anesthesia
Postoperative Care After Open Cholecystecomy
- 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
Discharge Teaching For After an Open Cholecystectomy
- S/S of infection
- Prevention of constipation
- Low-fat diet
- Activity level
- Routine care and teaching of T-tube management if present
Discharge Teaching For After an Open Cholecystectomy
- S/S of infection
- Prevention of constipation
- Low-fat diet
- Activity level
- Routine care and teaching of T-tube management if present
Nursing Management: Assessment and Analysis
- 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
Nursing Diagnoses
- 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
Nursing Assessments
- 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
Assessment: Vital Signs
- 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
Assessment: Serum Electrolytes
- measure imbalanced electrolytes d/t dehydration and lack of oral intake
- include BUN and Creatinine (elevated)
- with nasogastric tube (NG) suctioning, potassium monitored
Assessment: WBC
inflammation leads to an elevated WBC count
Assessment: Liver Enzymes and Bilirubin
Liver enzymes (AST, ALT, LDH, and ALP) and bilirubin are elevated b/c of blockage of bile flow in the bile ducts
Assessment: Skin turgor
decreased = dehydration
Assessment: Pain (onset, duration, exacerbating and relief factors)
- 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
Assessment: Abdominal distention, bowel sounds, Murphy’s sign
palpation may reveal rebound tenderness, muscle guarding, or rigid abdominal muscles d/t pain
Assessment: Stool
- Steatorrhea; presence of excess fat in stool or oily stools
- clay-colored stools d/t blockage of bile flow
Assessment: Daily weight
info in regard to fluid gains or losses
Assessment: Intake and Output
provide data about fluid volume status and prevent dehydration
Assessment: Nutritional Intake
determines diet hx, fat intake, foods that can contribute to symptoms
Nursing Actions
- 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
Actions: Maintain NPO
prevents gallbladder contraction that releases bile to break down nutrients; these contractions cause pain b/c of the inflamed gallbladder
Actions: Administer ordered antibiotics
short course of antibiotics may be given to reduce inflammation and treat infection
Actions: Administer ordered bile acid reducers
bile acid reducers help dissolve gallstones
Actions: Administer analgesics as ordered
- decrease symptoms of pain
- avoid morphine d/t spasm of the sphincter of Oddi
Actions: Administer antiemetic as ordered
decrease symptoms of N/V, which may occur for a prolonged time d/t abdominal pain and obstruction
Actions: Promote bedrest in semi-Fowler’s position
- avoid lying flat; makes pain worse; stretches the abdominal muscles when supine
- repositioning helps alleviate abdominal pain and pressure
Actions: NG tube to low suction (intermittent or continuous based on type of tube)
used to decompress the stomach and remove gastric secretions
Nursing Teachings
- Postoperative instructions
- T-tube management
- Avoid diet high in saturated fats
- Disease clinical manifestations, progression, diagnostic procedures, and interventions
Teaching: Avoid a diet high in saturated fats
- 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
Evaluating Care Outcomes
- 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
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. Obesity
C. Female
E. European Descent
Connection Check: The nurse correlates which clinical manifestation with cholecystitis? A. Retroperitoneal pain B. Absence of bowel sounds C. Diarrhea D. RUQ pain
D. RUQ pain
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
D. Morhpine
>usually contraindicated for pain management b/c it can cause the sphincter of Oddi to spasm, which results in pain
