N201 MEDSURG 2: Cholelithiasis & Cholecystitis

2 common types of gallbladder disease

- Cholelithiasis - Cholecystitis

What are the risk factors of gallbladder disease?

- Female - Multiple pregnancies - Age older > 40 yrs - Estrogen therapy - Obesity - Sedentary -Genetics (An obese women over 40 yrs old had multiple pregnancies & sedentary w/ family history of gallbladder disease and doing estrogen therapy)

What diagnostic test would the nurse expect the doctor to order?

- Ultrasound (used to diagnose gallstone, good for pt allergic to contrast medium) -Xray (determine blockage) - ERCP-Endoscopic Retrograde Cholangiopancreatography (allow visualization to gallbladder, cystic ducts, common ducts,--->>> bile need to send for culture sensitivity) -- Percutaneous transhepatic cholangiography (contrast dye injected into gallbladder)

What are the lab test expected findings for cholelithiasis & Cholecystitis?

- increase WBC (due to inflammation) - increase Serum & urinary bilirubin level (due to obstruct flow of bile secondary to gallstone) - increase Liver enzymes level (AST 0-35; ALT 4-36) - increase Serum amylase leveL

INTERPROFESSIONAL CARE: NUTRITIONAL THERAPY What diet you might expect the PCP will order?

- small, frequent meals w/ some fat - diet low in saturated fats - high fiber & calcium - reduce-calorie diet if pt is obese - avoid rapid weight loss

What is Cholelithiasis? What is Cholecystitis?

- stones in the bladder - inflammation of the gallbladder

What are the clinical manifestation of obstructed bile flow?

-Dark amber urine (due to increase water soluble-conjugated bilirubin elimination in urine - Clay colored stools (due to no bilirubin reaching the small intestines to be converted to urobiliubin - Pruritus (due to deposits of bile in skin tissues - Intolerance to fatty foods (due to no bile in small intestines for fat digestions - Steatorrhea or oily stools (undigested fats components of foods in stools due to no bile coming to the intestine emulsify fats ***Think about the function of bile***

INTERPROFESSIONAL CARE: CHOLELITHIASIS What are the drugs therapy that the doctors may order?

1. Opioids for pain control (morphine, bad effect: CNS & respiratory depression, constipation-->> monitor vital signs, increase fiber & fluids for constipation) 2. Antibiotic treatment (treat gallbladder wall infections, puss --->>> monitor WBC count 5-10k norm) 3. Anticholinergics for muscle relaxant (ex. atropine & antispasmodics

Postoperatively, a patient with an incisional cholecystectomy has a nursing diagnosis of ineffective breathing pattern related to splinted respirations secondary to a high abdominal incision. Which action should the nurse take first? Assess heart and lung sounds. Administer the prescribed analgesic. Position the patient on the operative side. Instruct the patient to cough and deep breathe.

Administer the prescribed analgesic.

What is the CAUSES of Cholelithiasis & Cholecystitis

Cholelithiasis: Unknown. Bile secreted by liver is supersaturated with cholesterol. Cholesterol, bile salts, bilirubin, and protein, and calcium precipitates-->> form a gallstone Cholecystitis: - associated with stones in the gallbladder causing obstruction -Increased bile viscosity due to fever, dehydration, prolonged absence of oral feeding (fasting), immobility, adhesions, cancer, opioids, and anesthesia

What is the etiology/pathophysiology of Cholelithiasis & Cholecystitis

Cholelithiasis: - unbalance concentration of cholesterol, bile salts, calcium in solution - bile stasis precipitates lead to progression of supersaturation--> change bile composite (bile sludge=GALLSTONES) - factors such as immobility, pregnancy (delays emptying of gallbladder due to hormonal factors), and inflammatory or obstructive lesions in the biliary system decrease bile flow. - stones can move to cystic ducts or common bile duct ---> cause pain, dislodge in ducts & cause blockage/obstruction (major complications) Cholecystitis: - Inflammation of the gallbladder wall -Occluded cystic duct -Scarring of gallbladder wall after acute attack.

What are the clinical manifestation of gallstone? What are the clinical manifestation Cholecystitis?

Cholelithiasis: - vary from severe to none at all - Steady, excruciating, severe pain (when stones is moving or obstructing the ducts - Tachycardia, diaphoresis, prostration (compensation to pain) -Referred pain to shoulder & scapula - Residual tenderness in RUQ - Pain occur 3-6 hrs after high fat meal or when pt lie down Cholecystitis: - moderate/severe pain & RUQ tenderness - fever, chills (due to inflammation results in leukocytosis or WBC increase--->> monitor infections) - jaundice (due to no bile flow into duodenum, bilirubin accumulates in blood

A nurse is caring for a client who has suspected cholecystitis. The nurse should expect the client's urine to appear which of the following colors? A. Pale yellow B. Greenish-brown C. Red D. Dark and amber

D. Dark and amber Rationale: Due ti increase water soluble (conjugated) bilirubin elimination in the urine.

INTERPROFESSIONAL CARE: What are the treatment option for clients with Cholelithiasis/gallstone?

Goal: Remove stone -based on the stage of disease 1. Oral dissolution therapy (bile acid-cholesterol solvents to dissolve stones; bad effect: recur stone formation; ex. Ursodeoxycholic acid & Chenodeoxycholic acid 2. ERCP w/ sphincterotomy (used to remove stones; allow visualization, cut & open, stones is drain into small intestines; bad effects: bleeding, infection 3. Extracorporeal shockwave lithotripsy (ESWL): (if stones cannot be removed via endoscopy; high energy shock waves disintegrate stones; take 1-2 hrs; used in conjunction with bile acids therapy. 4. Surgical Therapy: treatment of choice a) Laparoscopic Cholecystectomy (for pt w/ symptomatic gallstone; remove stones via 4 puncture holes; Good: minimal pain, resume normal activities-work w/in 1 week, small band aids/usually shower next day b) Open (incisional)cholecystectomy (for pt w/ complicated gallstones; removal of stones via right subcostal incision; bad effect: not quick recovery time

Which characteristics are most commonly associated with cholelithiasis (select all that apply). a. Obesity b. Age over 40 years c. Multiparous female d. History of excessive alcohol intake e. Family history of gallbladder disease f. Use of estrogen or oral contraceptives

a, b, c, e, f. Incidence of cholelithiasis is higher in women, multiparous women, persons over 40 years of age, and those with family history and obesity. Postmenopausal women taking estrogen replacement therapy and younger women on oral contraceptives have a higher incidence. Alcohol intake and diet do not increase the incidence of cholelithiasis.

Acalculous cholecystitis is diagnosed in an older, critically ill patient. Which factors may be associated with this condition (select all that apply)? a. Fasting b. Hypothyroidism c. Parenteral nutrition d. Prolonged immobility e. Streptococcus pneumoniae f. Absence of bile in the intestine

a, c, d. Acalculous cholecystitis is associated with prolonged immobility, fasting, prolonged parenteral nutrition, and diabetes. Hypothyroidism, Streptococcus pneumoniae, and absence of bile in the intestine are unrelated to this condition.

What treatment for acute cholecystitis will prevent further stimulation of the gallbladder? a. NPO with NG suction b. Incisional cholecystectomy c. Administration of antiemetics d. Administration of anticholinergics

a. NPO and nasogastric (NG) suction prevent gallbladder stimulation from food or fluids moving into the duodenum. Laparoscopic cholecystectomy is used more often than incisional cholecystectomy, but both remove the gallbladder, not its stimulation. Administration of antiemetics decreases nausea and vomiting but does not decrease gallbladder stimulation. Anticholinergics counteract the smooth muscle spasms of the bile ducts to decrease pain.

The patient with suspected gallbladder disease is scheduled for an ultrasound of the gallbladder. What should the nurse teach the patient about this test? a. It is noninvasive and is a very reliable method of detecting gallstones. b. It is the only test to use when the patient is allergic to contrast medium. c. It will outline the gallbladder and the ductal system to enable visualization of stones. d. It is an adjunct to liver function tests to determine whether the gallbladder is inflamed

a. Ultrasonography is accurate in detecting gallstones and is a noninvasive procedure. Magnetic resonance cholangiopancreatography (MRCP) and endoscopic ultrasound (EUS) may also be used when the patient is allergic to contrast medium. An IV cholangiogram uses radiopaque dye to outline the gallbladder and ducts. Liver function studies will be increased if liver damage has occurred but do not indicate gallbladder disease.

What must the nurse do to care for a T-tube in a patient after a cholecystectomy? a. Keep the tube supported and free of kinks. b. Attach the tube to low, continuous suction. c. Clamp the tube when ambulating the patient. d. Irrigate the tube with 10-mL sterile saline every 2 to 4 hours.

a. The T-tube drains bile from the common bile duct until swelling from trauma has subsided, and bile can freely enter the duodenum. The tube is placed to gravity drainage and should be kept open and free from kinks to prevent bile from backing up into the liver. T he tube is not normally clamped or irrigated.

The nurse is planning care for a 48-year-old woman with acute severe pancreatitis. The highest priority patient outcome is a. maintaining normal respiratory function. b. expressing satisfaction with pain control. c. developing no ongoing pancreatic disease. d. having adequate fluid and electrolyte balance.

a. maintaining normal respiratory function.

A patient with an obstruction of the common bile duct has clay-colored fatty stools among other manifestations. What is the pathophysiologic change that causes this manifestation? a. Water-soluble (conjugated) bilirubin in the blood excreted into the urine b. Absence of bilirubin and bile salts in the small intestine prevents conversion to urobilinogen and fat emulsion and digestion c. Contraction of the inflamed gallbladder and obstructed ducts stimulated by cholecystokinin when fats enter the duodenum d. Obstruction of the common duct prevents bile drainage into the duodenum, resulting in congestion of bile in the liver and subsequent absorption into the blood

b. Absence of bilirubin and bile salts in the intestine lead to clay colored stools and steatorrhea. Soluble bilirubin in the blood excreted into the urine leads to dark urine. Contraction of the inflamed gallbladder leads to pain with fatty food intake. Obstruction of the common bile duct prevents bile drainage into the duodenum, with congestion of bile in the liver. Bilirubin absorption in the blood leads to jaundice.

The nurse recognizes that teaching a 44-year-old woman following a laparoscopic cholecystectomy has been effective when the patient states which of the following? a. I can expect yellow-green drainage from the incision for a few days. b. I can remove the bandages on my incision tomorrow and take a shower. c. I should plan to limit my activities and not return to work for 4 to 6 weeks. d. I will always need to maintain a low-fat diet since I no longer have a gallbladder.

b. I can remove the bandages on my incision tomorrow and take a shower.

A patient with chronic cholecystitis asks the nurse whether she will need to continue a low-fat diet after she has a cholecystectomy. What is the best response by the nurse? a. "A low-fat diet will prevent the development of further gallstones and should be continued." b. "Yes; because you will not have a gallbladder to store bile, you will not be able to digest fats adequately." c. "A low-fat diet is recommended for a few weeks after surgery until the intestine adjusts to receiving a continuous flow of bile." d. "Removing the gallbladder will eliminate the source of your pain that was associated with fat intake, so you may eat whatever you like."

c. After removal of the gallbladder, bile drains directly from the liver into the duodenum and a low-fat diet is recommended until adjustment to this change occurs. Most patients tolerate a regular diet with moderate fat intake but should avoid excessive fat intake, as large volumes of bile previously stored in the gallbladder are not available. Steatorrhea could occur with a large fat intake.

During discharge instructions for a patient following a laparoscopic cholecystectomy, what should the nurse include in the teaching? a. Keep the incision area clean and dry for at least a week. b. Report the need to take pain medication for shoulder pain c. Report any bile-colored or purulent drainage from the incisions. d. Expect some postoperative nausea and vomiting for several day

c. Bile-colored drainage or pus from any incision may indicate an infection and should be reported to the HCP immediately. The bandages on the puncture sites should be removed the day after surgery, followed by showering. Referred shoulder pain is a common and expected problem following laparoscopic procedures, when carbon dioxide used to inflate the abdominal cavity is not readily absorbed by the body. Nausea and vomiting are not expected postoperatively and may indicate damage to other abdominal organs and should be reported to the HCP

Which action should the nurse in the emergency department take first for a new patient who is vomiting blood? a. Insert a large-gauge IV catheter. b. Draw blood for coagulation studies. c. Check blood pressure (BP), heart rate, and respirations. d. Place the patient in the supine position.

c. Check blood pressure (BP), heart rate, and respirations (to determine s/s of hypotension that lead to shock)

Marie, a 51-year-old woman, is diagnosed with cholecystitis. Which diet, when selected by the client, indicates that the nurse's teaching has been successful? a. 4-6 small meals of low-fat foods daily b. High-fat, high-carbohydrate meals c. Low-fat, high-carbohydrate meals d. High-fat, low protein meals

c. Low-fat, high-carbohydrate meal

Which clinical manifestation would the nurse expect a client diagnosed with acute cholecystitis to exhibit? a. Melena, weakness, tachycardia b. Acute right lower quadrant (RLQ) pain, diarrhea, and dehydration c. Ecchymosis petechiae, and coffee-ground emesis d. Nausea, vomiting, and diaphoresis

d. Nausea, vomiting, and diaphoresis

Which assessment finding is of most concern for a 46-year-old woman with acute pancreatitis? a. Absent bowel sounds b. Abdominal tenderness c. Left upper quadrant pain d. Palpable abdominal mass

d. Palpable abdominal mass

After a laparoscopic cholecystectomy, what should the nurse expect to be part of the plan of care? a. Return to work in 2 to 3 weeks b. Be hospitalized for 3 to 5 days postoperatively c. Have a T-tube placed in the common bile duct to provide bile drainage d. Have up to 4 small abdominal incisions covered with small dressings

d. The laparoscopic cholecystectomy requires 1 to 4 small abdominal incisions to visualize and remove the gallbladder, and the patient has small dressings placed over these incisions. The patient with an incisional cholecystectomy is usually hospitalized for 2 to 3 days, whereas the laparoscopic procedure allows same-day or next-day discharge with return to work within 1 week. A T-tube is placed in the common bile duct after exploration of the duct during an incisional cholecystectomy

6. A 51-year-old woman had an incisional cholecystectomy 6 hours ago. The nurse will place the highest priority on assisting the patient to a. choose low-fat foods from the menu. b. perform leg exercises hourly while awake. c. ambulate the evening of the operative day. d. turn, cough, and deep breathe every 2 hours.

d. turn, cough, and deep breathe every 2 hours. (to prevent ineffective breathing)