Cholecystitis

A. Pruritis

A client is admitted with obstructive jaundice. Which signs and symptoms does the nurse expect to find upon assessment of the client? A. Pruritis B. Pale urine in increased amounts C. Pink discoloration of sclera D. Dark, tarry stools

B. Auscultate the client's abdomen in all four quadrants

A nurse cares for a client with acute cholecystitis with severe abdominal pain, diaphoresis, and extreme fatigue. Vital signs are HR 118, BP 95/70, RR 32, Temp 101 F. What is the nurse's priority action? A. Instruct the UAP to reposition the client B. Auscultate the client's abdomen in all four quadrants C. Administer an opioid analgesic

C. Direct bilirubin 2.1 mg/dL

A nurse in a clinic is reviewing the laboratory reports of a client who has suspected cholelithiasis. Which of the following is an expected finding? A. Blood amylase 80 units/L B. WBC 9,000/mm3 C. Direct bilirubin 2.1 mg/dL D. Alkaline phosphatase 25 units/L

B. "You might have shoulder pain after surgery"

A nurse is completing preoperative teaching for a client who is scheduled for a laparoscopic cholecystectomy. Which of the following should be included in the teaching? A. "the scope will be passed through your rectum" B. "You might have shoulder pain after surgery" C. "You will have a JP drain in place after surgery" D. "You should limit how often you walk for 1-2 weeks"

B. Resume a diet of choice C. Cleanse the puncture site using mild soap and water E. Report nausea and vomiting to the surgeon

A nurse is providing discharge teaching to a client who is postoperative following a laparoscopic cholecystectomy. Which of the following instructions should the nurse include in the teaching? (SATA) A. Take baths rather than showers B. Resume a diet of choice C. Cleanse the puncture site using mild soap and water D. Remove adhesive strips from the puncture site in 24 hours E. Report nausea and vomiting to the surgeon

D. This medication dissolves gallstones gradually over a period of two years.

A nurse is reviewing a new prescription for chenodiol with a client who has Cholelithiasis. Which of the following information should the nurse include in the teaching? A. This medication is used to decrease acute biliary pain B. This medication requires thyroid function monitoring every 6 months C. This medication is not recommended for clients who have diabetes mellitus D. This medication dissolves gallstones gradually over a period of two years.

A. Obesity

A nurse is reviewing risk factors with a client who has cholecystitis. The nurse should identify that which of the following as a risk factor for cholecystitis? A. Obesity B. Rapid Weight Gain C. Decreased blood triglyceride level D. Male sex

Blumberg's sign

Assessment of Cholecystitis · Diet- high fat/cholesterol, low fiber, high carbs · Fullness, abdominal distention, gas, dyspepsia, belching, vague upper right quadrant pain, anorexia, nausea, vomiting, fever § Especially after a fatty meal · Pain: can range from mild, persistent ache to a steady, constant pain in RUQ § Can radiate to right upper shoulder or scapula § Pain with deep inspiration during right subcostal palpation § Patterns of pain are usually episodic, and known as "gallbladder attacks" · Acute symptoms: § occur with obstruction and inflammation or infection § fever, palpable abdominal mass, § severe right abdominal pain radiating to the back or right shoulder, nausea and vomiting, tachycardia, pallor, and sweating · Biliary colic: severe pain caused by obstruction of cystic duct in gallbladder (gallstone) that is usually associated with nausea and vomiting, which usually occur several hours after a heavy meal. § Biliary colic can become severe enough to cause shock, so monitor for tachycardia, pallor, diaphoresis, and prostration (exhaustion). Notify the provider of symptoms and keep the patient flat. · Positive ____________________ (rebound tenderness) · Jaundice (obstructive) may develop due to blockage of the common bile duct & icterus (yellowing sclera) may occur; chronic more often § With build-up of bile salts, pt. reports itching or burning § may have clay-colored stools; urine becomes dark & foamy; steatorrhea

Biliary colic

Assessment of Cholecystitis · Diet- high fat/cholesterol, low fiber, high carbs · Fullness, abdominal distention, gas, dyspepsia, belching, vague upper right quadrant pain, anorexia, nausea, vomiting, fever § Especially after a fatty meal · Pain: can range from mild, persistent ache to a steady, constant pain in RUQ § Can radiate to right upper shoulder or scapula § Pain with deep inspiration during right subcostal palpation § Patterns of pain are usually episodic, and known as "gallbladder attacks" · Acute symptoms: § occur with obstruction and inflammation or infection § fever, palpable abdominal mass, § severe right abdominal pain radiating to the back or right shoulder, nausea and vomiting, tachycardia, pallor, and sweating · ___________________: severe pain caused by obstruction of cystic duct in gallbladder (gallstone) that is usually associated with nausea and vomiting, which usually occur several hours after a heavy meal. § ____________ can become severe enough to cause shock, so monitor for tachycardia, pallor, diaphoresis, and prostration (exhaustion). Notify the provider of symptoms and keep the patient flat. · Positive Blumberg's sign (rebound tenderness) · Jaundice (obstructive) may develop due to blockage of the common bile duct & icterus (yellowing sclera) may occur; chronic more often § With build-up of bile salts, pt. reports itching or burning § may have clay-colored stools; urine becomes dark & foamy; steatorrhea

Post-Cholecystectomy Syndrome (PCS)

Complications of Cholecystectomy § Obstruction of Bile Duct: this can cause ischemia, gangrene, and rupture of the gallbladder · S/S: decreased drainage, yellow drainage, jaundice · Gallbladder rupture: local abscess, peritonitis, rigid-board-like ABD, guarding § Bile Peritonitis: this can occur with adequate amounts of bile are not drained from the surgical site · S/S: pain, fever, jaundice · Intervention: REPORT TO PROVIDER § ____________________________: manifestations of gallbladder disease continue after surgery. Educate on things that cause Post-CholecystectomySyndrome: pseudocyst, common bile duct (CBD) leak, CBD/pancreatic duct obstruction or stricture, new gallstone, pancreatic or liver mass, sclerosing cholangitis, diverticular compression, CAD, neuritis, psychiatric disorder · Treatment is ERCP to find/fix the cause.

Cholecystitis

Diagnostics for ____________________: · Leukocytosis (increased WBCs) with inflammation · AST & LDH may be elevated indicating liver abnormalities with severe biliary obstruction · Direct & Indirect serum bilirubin elevated · If pancreas is involved, amylase & lipase may be elevated · X-rays and CT may show stones and enlarged gallbladder · Ultrasonography is best initial diagnostic test for gall stones and dilated common bile duct · Hepatobiliary scan (HIDA): visualizes gallbladder & patency of biliary system after injection of IV contrast. Patient must be NPO · ERCP to allow direct visualization using an endoscope that is inserted through the esophagus and into the common bile duct via the duodenum. Physician can remove gall stones in this procedure (sometimes done if etiology of symptoms is unknown)

§ At first, patients may decline food due to nausea, vomiting, and anorexia, so work with the dietician to enhance nutrition. § Diet should be high in fiber and low in fat. § Eat small, frequent meals § Weight the patient regularly to assess for weight gain/loss. § Avoid high fat foods and gas producing foods. § Loose weight

Non Surgical Treatment for Cholecystitis · Medications: § Pain meds: morphine, hydromorphone (Dilaudid), ?Demerol, Ketolorac (Toradol) § maybe antibiotics § Ursodiol (Actigall) or Chenodiol: bile acid to dissolve cholesterol gall stones gallstones; but have to have gallbladder ultrasound every 6 months x 1 year to see if it's working; ursodeoxycholic acid and chenodeoxycholic acid · Report ABD pain, diarrhea, or vomiting · Bowel rest · NPO · IV fluids · Dietary/Nutrition management - - - - -

Ursodiol (Actigall) or Chenodiol

Non Surgical Treatment for Cholecystitis · Medications: § Pain meds: morphine, hydromorphone (Dilaudid), ?Demerol, Ketolorac (Toradol) § maybe antibiotics § ____________________________________: bile acid to dissolve cholesterol gall stones gallstones; but have to have gallbladder ultrasound every 6 months x 1 year to see if it's working; ursodeoxycholic acid and chenodeoxycholic acid · Report ABD pain, diarrhea, or vomiting · Bowel rest · NPO · IV fluids · Dietary/Nutrition management § At first, patients may decline food due to nausea, vomiting, and anorexia, so work with the dietician to enhance nutrition. § Diet should be high in fiber and low in fat. § Eat small, frequent meals § Weight the patient regularly to assess for weight gain/loss. § Avoid high fat foods and gas producing foods. § Loose weight

Intracorporeal or extracorporeal lithotripsy

Nonsurgical removal/Treatment of Cholecystitis · ___________________: shock waves are used to break up stones § Instruct and assist the client to lay flat on a fluid-filled pad for delivery of shock waves and administer analgesia · Cholecystostomy (biliary drainage): transhepatic biliary catheter (good for non-surgical candidates) · Endoscopic treatment: ERCP to remove stones

Obesity, type 2 diabetes, dyslipidemia, insulin resistance

Risk Factors for Cholecystitis · Main risk factors: ____________________ · Increased age, female, family history, diet (excessive cholesterol) · American Indian, Mexican American, Caucasian · Acute: 4 F's (Female, forty, fat, fertile) · Chronic: young, women, athletic (ballerinas, gymnasts) · prolonged fasting, rapid weight loss, hormone replacement therapy, cholesterol-lowering drugs, prolonged parenteral nutrition, Crohn's disease, gastric bypass surgery, sickle cell disease, glucose intolerance, pregnancy, older age, low-calorie liquid protein diets

B. 35 year old American Indian who works in construction E. 64 year old Mexican American who resides with grandchildren

The community nurse is talking with four clients who have reported digestive concerns. Which client does the nurse recognize as most likely to experience gallstone production? (SATA) A. 23 year old Caucasian vegetarian who is a dancer B. 35 year old American Indian who works in construction C. 48 year old Canadian who manages a fast food restaurant D. 59 year old Asian American who is an investment banker E. 64 year old Mexican American who resides with grandchildren

A. You'll have a small, mid-line abdominal incision D. Generally the pain associated with this procedure is minimal E. This procedure has a low incidence of infection

The nurse will include what postoperative teaching when caring for the client who is preparing to undergo endoscopic cholecystectomy? (SATA) A. You'll have a small, mid-line abdominal incision B. You can't eat or drink for a few days after the procedure C. You won't be able to return to regular activity for several weeks D. Generally the pain associated with this procedure is minimal E. This procedure has a low incidence of infection F. The hospital stay after this procedure is typically 3-4 days

Calculous Cholecystitis

· Acute Cholecystitis 2 types: - ________________: chemically irritation of the gallbladder due to gallstones (cholelithiasis) that obstruct the cystic duct, gallbladder neck, or common bile duct. Trapped bile is absorbed and irritates the gallbladder wall. · Reabsorbed bile (in combination with impaired circulation, edema, and gallbladder distention) cause ischemia and infection, resulting in sloughing with necrosis and gangrene (possible rupture of the gallbladder). · If perforation/rupture occurs is small, an access may form, but if perforation/rupture occurs is large, peritonitis may occur · Gallstones are composed of substances found in bile (cholesterol, bilirubin, bile salts, calcium, proteins) and are classified as cholesterol or pigment stones. -- Cholesterol Gallstones form due to imbalances of cholesterol and bile salts -- Pigment stones develop from excess bilirubin · most common

Acalculous Cholecystitis

· Acute Cholecystitis 2 types: -______________ - inflammation of the gallbladder without gallstones. It is associated with biliary stasis (usually due to anatomic problems, like twisting or kinking, that affect filling/emptying of gallbladder). This mostly occurs in patients with sepsis, severe trauma/burns, long-term PN, multiple organ dysfunction syndrome, major surgery, hypovolemia

Obstructive Jaundice

· Chronic Cholecystitis: this cholecystitis occurs when repeated episodes of cystic duct obstruction, cause inflammation and gallstones. The Gallbladder becomes fibrotic and contracted, resulting in decreased motility and deficient absorption. § Jaundice (yellow skin) and Icterus (yellow sclera) occur § _______________________ occurs with obstructed bile flow. Accumulation of bile salts leads to pruritis or burning of the skin. Clay-colored stools and dark, foamy urine also result § Complications: pancreatitis and cholangitis (bile duct inflammation)

pacemakers

· ERCP to allow direct visualization using an endoscope that is inserted through the esophagus and into the common bile duct via the duodenum. Physician can remove gall stones in this procedure (sometimes done if etiology of symptoms is unknown) § Preprocedure Endoscopic Retrograde Cholangiopancreatography (ERCP): · Informed consent, ask about allergies to contrast media · NPO for 6-8 hours · Assess CBC, PTT, Pt, INR, Liver Function, X-rays, ECG · Assess age, health status, cognitive status, support system, recent food intake, medications, previous barium studies, electrolyte/fluid status · IV access obtained for moderate sedation drugs · Dentures are removed · Ask about _____________________ (can be affected by electrocautery) · Ask about anticoagulants, NSAIDs, antiplatelets, antihyperglycemics (metformin)

sternal rub

· ERCP to allow direct visualization using an endoscope that is inserted through the esophagus and into the common bile duct via the duodenum. Physician can remove gall stones in this procedure (sometimes done if etiology of symptoms is unknown) § Preprocedure Endoscopic Retrograde Cholangiopancreatography (ERCP): · Informed consent, ask about allergies to contrast media · NPO for 6-8 hours · Assess CBC, PTT, Pt, INR, Liver Function, X-rays, ECG · Assess age, health status, cognitive status, support system, recent food intake, medications, previous barium studies, electrolyte/fluid status · IV access obtained for moderate sedation drugs · Dentures are removed · Ask about pacemakers (can be affected by electrocautery) · Ask about anticoagulants, NSAIDs, antiplatelets, antihyperglycemics (metformin) § Intraprocedure Endoscopic Retrograde Cholangiopancreatography (ERCP): · Care is similar to EGD · Patient is initially placed semi-prone on a Tilt Table with repositioning to move contrast media for different pics - Left lateral position to check common bile duct - Prone to look at biliary tree · A bite block is placed to prevent biting down on the endoscope and to protect teeth · monitor respiratory status because drugs for sedation can depress the rate and depth of respirations. Monitor oxygen saturation · If the patient's respirations falls below 10/min or the exhaled CO2 level falls below 20%, the nurse should use a _________________________ to encourage deeper, faster respirations

drive for 12-18 hours after procedure

· ERCP to allow direct visualization using an endoscope that is inserted through the esophagus and into the common bile duct via the duodenum. Physician can remove gall stones in this procedure (sometimes done if etiology of symptoms is unknown) § Preprocedure Endoscopic Retrograde Cholangiopancreatography (ERCP): · Informed consent, ask about allergies to contrast media · NPO for 6-8 hours · Assess CBC, PTT, Pt, INR, Liver Function, X-rays, ECG · Assess age, health status, cognitive status, support system, recent food intake, medications, previous barium studies, electrolyte/fluid status · IV access obtained for moderate sedation drugs · Dentures are removed · Ask about pacemakers (can be affected by electrocautery) · Ask about anticoagulants, NSAIDs, antiplatelets, antihyperglycemics (metformin) § Intraprocedure Endoscopic Retrograde Cholangiopancreatography (ERCP): · Care is similar to EGD · Patient is initially placed semi-prone on a Tilt Table with repositioning to move contrast media for different pics o Left lateral position to check common bile duct o Prone to look at biliary tree · A bite block is placed to prevent biting down on the endoscope and to protect teeth · monitor respiratory status because drugs for sedation can depress the rate and depth of respirations. Monitor oxygen saturation · If the patient's respirations falls below 10/min or the exhaled CO2 level falls below 20%, the nurse should use a sternal rub to encourage deeper, faster respirations § Post-procedure Endoscopic Retrograde Cholangiopancreatography (ERCP): · Assess vitals every 15 minutes until stable. (priority: prevent aspiration) · Ensure gag reflex has returned before offering fluids or food. Discontinue IV when patient con tolerate oral food and fluids without nausea/vomiting · Instruct patient to report ABD pain, fever, nausea, or vomiting that doesn't resolve after returning home · Do not ___________________ · Notify the provider of bleeding, chest pain, ABD pain, infection · Teach the patient/family to monitor or Postprocedure complications at home: cholangitis, bleeding, pancreatitis, sepsis, perforation -Severe pain is present in all complications -Fever indicates sepsis - May take hours to 2 days to develop complications

Post-Cholecystectomy Syndrome (PCS)

· Laparoscopic cholecystectomy: gold standard for removing gallbladder § Pre-op labs/medications, informed consent, NPO § The surgeon explains the procedure. The nurse answers questions and reinforced the instructions. § Reinforce what to expect after surgery, deep breathing exercises, incisional care, and leg exercises (to prevent DVT) § After the procedure, assess O2 sat frequently until anesthesia wears off. Remind the patient to perform deep-breathing every hour § Monitor for N/V (treat with antiemetics, ondansetron, and have HOB elevated to prevent aspiration) § assess for gag reflex return before giving food/fluids § Give pain meds and use ice for incisional pain § Rest for 24 hours, then begin slowly resuming normal activities § Monitor for bile leak: pain, vomiting, ABD distention § A large intake of fatty foods can induce ____________________________, so introduce fatty foods one at a time

· Monitor and record drainage: initially it is serosanguineous stained with green-brown bile) · Antibiotics are often prescribed to decrease risk of infection

· Open Cholecystectomy (less common) is surgical removal of the gallbladder 1. Preoperative Care for Open Cholecystectomy § NPO, informed consent, pre-op labs and medications 2. Operative care Cholecystectomy § Surgeon may place a T-tube in common bile duct possible - especially if complications § Surgeon may place a JP drain for drainage around gallbladder bed. Drainage from this system should be serosanguinous (clear, blood-tinged) and is stained with bile for the first 24 hours. 3. Postoperative Care Cholecystectomy § Postop incisional pain is controlled with opioids or PCAs § Patient may need antiemetics for post-op N/V § Low Fowler's position § May have NG § NPO until bowel sounds return, then a clear liquid to soft, low-fat, high-carbohydrate diet postoperatively § Care of biliary drainage system: - - § Care of T-Tube: · Report absence of drainage with symptoms of nausea and pain (obstruction) · Inspect skin around tube for infection or bile leakage · If prescribed, elevate T-tube above the level of ABD to prevent total loss of bile · Monitor and record color/amount of drainage · Clamp the tube 1hr before and after meals to provide bile needed for digestion · Assess stools for color: clay colored stools are expected until biliary flow is reestablished (about a week), diarrhea may occur · Monitor for bile peritonitis (pain, fever, jaundice) · Expect removal of the tube in 1-3 weeks § Administer analgesics as ordered and medicate to promote/permit ambulation and activities, including deep breathing § Turn, and encourage coughing and deep breathing, splinting to reduce pain § Ambulation: resume activity gradually, but avoid heavy lifting for 4-6 weeks. § Take showers instead of baths until drainage tube is removed § Diet: begin with clear liquids and advance to solid food as peristalsis returns · avoid fatty foods: fried food, butter, fast food, gravies, chocolate, nuts. · Avoid gas-forming foods: beans, cabbage, cauliflower, broccoli · If obese, lose weight. · Take fat-soluble vitamins or bile salts as prescribed to enhance absorption and aid with digestion

· Report absence of drainage with symptoms of nausea and pain (obstruction) · Inspect skin around tube for infection or bile leakage · If prescribed, elevate T-tube above the level of ABD to prevent total loss of bile · Monitor and record color/amount of drainage · Clamp the tube 1hr before and after meals to provide bile needed for digestion · Assess stools for color: clay colored stools are expected until biliary flow is reestablished (about a week), diarrhea may occur · Monitor for bile peritonitis (pain, fever, jaundice) · Expect removal of the tube in 1-3 weeks

· Open Cholecystectomy (less common) is surgical removal of the gallbladder 1. Preoperative Care for Open Cholecystectomy § NPO, informed consent, pre-op labs and medications 2. Operative care Cholecystectomy § Surgeon may place a T-tube in common bile duct possible - especially if complications § Surgeon may place a JP drain for drainage around gallbladder bed. Drainage from this system should be serosanguinous (clear, blood-tinged) and is stained with bile for the first 24 hours. 3. Postoperative Care Cholecystectomy § Postop incisional pain is controlled with opioids or PCAs § Patient may need antiemetics for post-op N/V § Low Fowler's position § May have NG § NPO until bowel sounds return, then a clear liquid to soft, low-fat, high-carbohydrate diet postoperatively § Care of biliary drainage system: · Monitor and record drainage: initially it is serosanguineous stained with green-brown bile) · Antibiotics are often prescribed to decrease risk of infection § Care of T-Tube: - - - - § Administer analgesics as ordered and medicate to promote/permit ambulation and activities, including deep breathing § Turn, and encourage coughing and deep breathing, splinting to reduce pain § Ambulation: resume activity gradually, but avoid heavy lifting for 4-6 weeks. § Take showers instead of baths until drainage tube is removed § Diet: begin with clear liquids and advance to solid food as peristalsis returns · avoid fatty foods: fried food, butter, fast food, gravies, chocolate, nuts. · Avoid gas-forming foods: beans, cabbage, cauliflower, broccoli · If obese, lose weight. · Take fat-soluble vitamins or bile salts as prescribed to enhance absorption and aid with digestion

Low Fowler's position

· Open Cholecystectomy (less common) is surgical removal of the gallbladder 1. Preoperative Care for Open Cholecystectomy § NPO, informed consent, pre-op labs and medications 2. Operative care Cholecystectomy § Surgeon may place a T-tube in common bile duct possible - especially if complications § Surgeon may place a JP drain for drainage around gallbladder bed. Drainage from this system should be serosanguinous (clear, blood-tinged) and is stained with bile for the first 24 hours. 3. Postoperative Care Cholecystectomy § Postop incisional pain is controlled with opioids or PCAs § Patient may need antiemetics for post-op N/V § ________________________ position § May have NG § NPO until bowel sounds return, then a clear liquid to soft, low-fat, high-carbohydrate diet postoperatively § Care of biliary drainage system: · Monitor and record drainage: initially it is serosanguineous stained with green-brown bile) · Antibiotics are often prescribed to decrease risk of infection § Care of T-Tube: · Report absence of drainage with symptoms of nausea and pain (obstruction) · Inspect skin around tube for infection or bile leakage · If prescribed, elevate T-tube above the level of ABD to prevent total loss of bile · Monitor and record color/amount of drainage · Clamp the tube 1hr before and after meals to provide bile needed for digestion · Assess stools for color: clay colored stools are expected until biliary flow is reestablished (about a week), diarrhea may occur · Monitor for bile peritonitis (pain, fever, jaundice) · Expect removal of the tube in 1-3 weeks § Administer analgesics as ordered and medicate to promote/permit ambulation and activities, including deep breathing § Turn, and encourage coughing and deep breathing, splinting to reduce pain § Ambulation: resume activity gradually, but avoid heavy lifting for 4-6 weeks. § Take showers instead of baths until drainage tube is removed § Diet: begin with clear liquids and advance to solid food as peristalsis returns · avoid fatty foods: fried food, butter, fast food, gravies, chocolate, nuts. · Avoid gas-forming foods: beans, cabbage, cauliflower, broccoli · If obese, lose weight. · Take fat-soluble vitamins or bile salts as prescribed to enhance absorption and aid with digestion

Cholecystitis

· ___________________: Inflammation of the gallbladder that can be acute or chronic. It is most often caused by gallstones obstructing the cystic duct or common bile duct causing backup of bile which irritates/inflames the gallbladder. · Cholelithiasis is the presence of stones in the gallbladder related to the precipitation of either bile or cholesterol into stones. · Bile is used for the digestion of fats. It is produced in the liver and stored in the gall bladder.

Chronic Cholecystitis

· ____________________: this cholecystitis occurs when repeated episodes of cystic duct obstruction, cause inflammation and gallstones. The Gallbladder becomes fibrotic and contracted, resulting in decreased motility and deficient absorption. § Jaundice (yellow skin) and Icterus (yellow sclera) occur § Obstructive Jaundice occurs with obstructed bile flow. Accumulation of bile salts leads to pruritis or burning of the skin. Clay-colored stools and dark, foamy urine also result § Complications: pancreatitis and cholangitis (bile duct inflammation)