NUR221 APPENDICITIS, CHOLECYSTITIS
Appendicitis Post-op Care
-NPO until BS return -Ask about flatus -Monitor urine output -Early ambulation ↓DVT risk Discharge Instructions - Make & keep appointments - Monitor for s/s infection --Teach back -Avoid lifting -Return to normal activities 2-4weeks -Longer healing times for perforation or open abdominal surgeries
Cholecystitis medical management
-Nutritional supportive therapy --Relieves inflammation thru rest, nasogastric suctions, analgesia, IV fluids, antibiotics. -Delay Surgery til ↓inflammation -Diet
Cholecystitis manifestations
-RUG pain that radiates to right shoulder -Fever w/chills -Tachycardia -Epigastric Distress -Episodic colicky pain after eating (esp fatty foods) -Pain may refer to the right scapula -Anorexia and feeling of fullness -Positive murphy's sign -Abdominal pain in RUQ, vague -N&V, Heartburn -Jaundice -Changes in urine or stool color, clay stool -Vitamin Deficiency -ADEK
peritonitis
inflammation of the peritoneum -abdominal pain and distention -tachycardia -tachypnea -nausea, vomiting -fever -shock --hypotension, tachycardia, tachypnea
portal pylephlebitis
-complication of appendicitis -Fever, rigor, URQ pain, jaundice, and elevated liver enzymes -Very Rare -Caused by emboli from septic intestines
Appendicitis Complications
-gangrene -perforation, rupture --usually 6-24h after onset -peritonitis -↑ fever, tachy, rebound tenderness, rigid/board-like abdomen -Abscess -Portal pylephlebitis - very rare
Causes of cholecystitis
- gallstones - tumor - bile duct blockage - infection - blood vessel problems -trauma, burns, major surgical procedures - disrupts biliary outflow of gallbladder
Cholecystitis Assessment & Diagnostics
-Abdominal X-ray -Ultrasonography -Radionuclide Imaging or Cholescintigraphy if u/s inconclusive -Oral cholecystography (shellfish/contrast allergy) -ERCP -PTC
Appendicitis: Assessment & Diagnostics
-CBC - elevated WBC(neutrophils) -Elevated C-Reactive Protein(gangrene) -CT scan - >6mm = appendicitis -Ultrasound, MRI
Cholelithiasis
-Calculi - or gall stones -Vary in size & shape -Can be asymptomatic -Pain can be caused by inflammation of the gallbladder or obstructed bile duct
shock
A condition in which the circulatory system fails to provide sufficient circulation to enable every body part to perform its function; also called hypoperfusion. -hypotension -tachycardia -tachypnea
The nurse in the emergency department is admitting a client with cholecystitis who is experiencing pain and nausea. Which action should the nurse take first? Administer an oral electrolyte solution. Administer pain medication. Finish obtaining a complete admission history. Tell the client about planned diagnostic tests.
Administer pain medication. *Administering pain medication would have the highest priority during the first hour after the client's admission. Completing the admission history can be done after the client's pain is controlled. Maintaining hydration is important but likely will be administered intravenously since the client is nauseated. It is not appropriate to try to teach while a client is in pain. Teaching about planned diagnostic tests can occur after the client is comfortable.
endoscopic retrograde cholangiopancreatography (ERCP)
Flexible endoscope down throat -IV fuids -Meds -VS - resp, hypotension -Vomiting
Obturator sign
RLQ on internal rotation of right thigh indicative of appendicitis
percutaneous transhepatic cholangiography (PTC)
X-ray of liver and bile duct after dye is injected directly into liver -for pt who can't do ERCP -Monitor for: --bleeding --peritonitis --sepsis
A nurse is assigning the care of a client admitted with appendicitis. The nurse should assign this client's care to: a registered nurse pulled from the cardiac unit. a licensed practical nurse with pediatric experience. a registered nurse with geriatric experience. a graduate nurse awaiting N-CLEX results.
a registered nurse pulled from the cardiac unit. *According to the National Council of State Boards of Nursing, delegation encompasses five rights — the right task, right circumstance, right person, right direction and communication, and right supervision and evaluation. This client requires frequent assessment and monitoring. The nurse should assign the client's care to a registered nurse because the client may need immediate nursing action if the appendix ruptures. The client does not require the specialized knowledge of a clinical nurse specialist. It is not appropriate to delegate the licensed practical nurse. Since appendicitis is uncommon in the elderly population, the cardiac nurse would be a better choice.
A client with cholecystitis is receiving propantheline bromide. The client is given this medication because it slows emptying of the stomach and reduces chyme in the duodenum. inhibits contraction of the bile duct and gallbladder. reduces gastric solution production and hypermotility. decreases bile secretions.
decreased biliary spasm *Propantheline bromide is an anticholinergic used to decrease biliary spasm. Decreasing biliary spasm helps reduce pain in cholecystitis. Propantheline does not increase bile production or have an antiemetic effect, and it is not effective in treating infection.
Acalculous Cholecystitis
inflammation in the absence of obstruction
Cholesystitis diet
low-fat liquids, high protein carb powder, cooked rice, tapioca, lean meats, mashed potatoes, non gassy veggies, bread, coffee tea - as tolerated -AVOID - eggs, cream, pork, fried foods, cheese, rich dressings, gassy foods, alcohol
The nurse is assessing a client who has cholecystitis caused by gallstones (cholelithiasis). Which finding should the nurse report to the health care provider? elevated temperature of 103°F (39.4°C) black stools decreased white blood cell count nausea after ingestion of high-fat foods
nausea after ingestion of high-fat foods *A client with cholecystitis from cholelithiasis may experience nausea, vomiting, abdominal discomfort, and other gastrointestinal symptoms after eating high-fat foods. This is due to decreased fat absorption related to a lack of normal bile flow from the gallbladder.
Biliary Colic
pain in the gallbladder caused by gallstones obstructing bile flow
Murphy's sign
pain with palpation of the RUQ during inspiration, indicative of cholecystitis
Complications of appendicitis
perforation, peritonitis, abscess
cholesystectomy
-surgical removal of the gallbladder -open -laparoscopic
Appendicitis Nursing Management
-Relieve pain(after diagnosed) -Prevent Fluid Volume Deficits -Reduce Anxiety -Prevent surgical site infections -Prevent atelectasis -Maintain skin integrity -Ambulate safely -Change positions --↑ Fowler's ---Relieves tension on ABD organs --Deep Breathing/Incentive Spirometer
Appendicitis Medical Management
-Surgery --Laparoscopy - smaller incision-quicker healing --Laparotomy - complex cases -Antibiotics -Fluid replacement
Appendicitis Clinical Manifestations
-Vague Periumbilical pain -Localizes to RLQ pain -Anorexia -Vague pain over a couple days or sudden -N&V -Fever -Tenderness at McBurney's point -Rebound tenderness -Constipation
cholescintigraphy
-imaging test used to examine the function of the liver, gallbladder, and bile ducts -if u/s inconclusive(not stones)
Cholecystitis
-inflammation of the gallbladder (acute or chronic
A client with appendicitis suddenly develops tachycardia and tachypnea with a high fever. Which interventions would have the highest priority?
-Call the surgeon as the appendix may have perforated -IV Normal Saline -Maintain NPO status
Cholecystitis Procedures
-Dissolving Stones -Stone removal by instrument -Intracorporeal Lithotripsy -Extracorporeal Shock Wave Lithotripsy
Cholecystitis Post-op Care
-Early Ambulation -Deep Breathe & cough -No baths - shower only -Report redness/swelling at incision site -lose weight -avoid fatty foods
calculous cholecystitis
-Gallbladder inflammation associated with gallstones -most common - 90%
Appendicitis in Elderly
-Harder to dx -Vague s/s -Mild pain or no pain -often misdx as a bowel obstruction -No fever -No leukocytosis -higher mortality
Appendicitis
-Inflammation of the appendix d/t inadequate emptying or obstruction -Ages 10-30 -Slightly more common in males -Familial predisposition
Cholelithiasis Risk Factor
Cystic Fibrosis Diabetes Frequent weight changes Ileal resection or disease low-dose estrogen Obesity Women Multiple pregnancies Native American Hispanic Over 40 High fat diet
Cholecystitis Surgery
PRE-OP -CXR, ECG, LFT, PT level, CBC Laparoscopic Cholecystectomy -resume activities in 1 week. COMPLICATIONS -bile duct injury -bile leak symptoms start several days after procedure -Bile peritonitis - rare complication - serious illness or death.
The nurse is admitting a client with acute appendicitis to the emergency department. The client has abdominal pain of 10 on a pain scale of 1 to 10. The client will be going to surgery as soon as possible. What should the nurse do next? Apply heat to the abdomen in the area of the pain. Maintain the client in a recumbent position. Contact the surgeon to request a prescription for a narcotic for the pain. Place the client on nothing-by-mouth (NPO) status.
Place the client on nothing-by-mouth (NPO) status.
Psoas sign
RLQ pain with extension of right thigh indicative of appendicitis
A client is admitted to the hospital with a diagnosis of cholecystitis. The client has severe abdominal pain and nausea and has vomited 120 mL. Based on these data, which nursing action would have the highest priority at this time? Replace nutritional loss. Manage the pain. Manage anxiety. Restore fluid loss.
The priority for nursing care at this time is to decrease the client's severe abdominal pain. The pain, which is frequently accompanied by nausea and vomiting, is caused by biliary spasms. Opioid analgesic medications are given to relieve the severe pain and spasms of cholecystitis. Relief of pain may decrease nausea and vomiting and thereby decrease the client's likelihood of developing further complications, such as severe fluid loss and inadequate nutrition. There are no data to suggest that the client is anxious.
A client with acute appendicitis develops a fever, tachycardia, and hypotension. Based on these findings, the nurse should further assess the client for which complication? bowel ischemia deficient fluid volume intestinal obstruction peritonitis
peritonitis *Complications of acute appendicitis are perforation, peritonitis, and abscess development. Signs of the development of peritonitis include abdominal pain and distention, tachycardia, tachypnea, nausea, vomiting, and fever. Because peritonitis can cause hypovolemic shock, hypotension can develop.
Blumberg's sign
rebound tenderness. - appendicitis -cholecystitis - peritonitis/perforation - diverticulitis
A client with appendicitis is experiencing excruciating abdominal pain. An abdominal X-ray film reveals intraperitoneal air. What should the nurse prepare the client for? surgery colonoscopy nasogastric (NG) tube insertion barium enema
surgery *The client should be prepared for surgery because the signs and symptoms indicate bowel perforation. Appendicitis is a common cause of bowel perforation. Because perforation can lead to peritonitis and sepsis, surgery would not be delayed to perform other interventions, such as colonoscopy, NG tube insertion, or a barium enema. These procedures are not necessary at this point.
A client comes to the emergency department with suspected cholecystitis. Which data collection findings are characteristic of this diagnosis? Select all that apply. burning in the chest after eating fried foods flatulence nausea urticaria transient epigastric pain radiating to the back and right shoulder
transient epigastric pain radiating to the back and right shoulder burning in the chest after eating fried foods flatulence nausea *Cholecystitis (inflammation of the gallbladder) is characterized by epigastric pain that radiates to the back and right shoulder. This pain commonly occurs after eating foods high in fat, especially those that are fried. A client with cholecystitis may also experience nausea, vomiting, and flatulence. Urticaria is not commonly associated with cholecystitis.
