nursing 124; gallbladder disease (mod 10)set #2
A patient recovering from a cholecystectomy and T-tube placement is prescribed an analgesic medication as needed, nasogastric tube placement, minimal ice chips, and monitoring of T-tube drainage. Which patient statement should cause the nurse to notify the healthcare provider? ANSWER "I must be better because there's no drainage in the bag." "I saw some fluid coming out of my NG tube." "Is this drainage supposed to be green?" "My pain feels like it's about 8 out of 10."
"I must be better because there's no drainage in the bag." The tube normally drains up to 500 mL in the first 24 hours after surgery; drainage decreases to less than 200 mL in 2-3 days and is minimal thereafter; HOWEVER, NEVER STOP COMPLETELY. Small amounts of NG drainage are expected, particularly after the patient eats ice chips. Pain is managed by a narcotic analgesic, so the nurse should administer these as prescribed. Green drainage from the T-tube is expected. (extra; During an acute gallbladder attack/cholecystitis, the patient may complain of severe right upper quadrant pain that radiates to the right scapula and shoulder. The pain is often aggravated by movement and breathing and last from 12 -18 hours. also include chils and fever)
colon resection perioperative
Preop colon resection assessment and interventions include antibiotics, bowel prep might be required (careful consideration if elderly to monitor for dehydration), NGT (usually not necessary if surgery will be laparoscopic), PIV, NPO, other assessment criteria discussed in perioperative concept into presentation. Post op- Assessment of colon resection same as cholecystectomy.VS, including temp per protocol and then q4 hours, tachycardia, increased RR, or elevated temp could indicate infection; assist with cough, deep breathing, and using IS (Incentive Spirometer) q 1-2 WA(when awake). Monitor o2 sats Splint abdomen with blanket or pillow during coughing. There is an increased risk for atelectasis and respiratory infections like PNA with an open chole as the high incision makes it uncomfortable to breath deeply; fowler position, encourage ambulation, administer antibiotics as prescribed If a colostomy was created, pt. likely returns with NGT in place and needs careful monitoring of the stoma- should be reddish/ pink, moist, protrude 1-3 cm from abdominal wall, small amount of bleeding up to 6-8 weeks post op. Immediately contact the surgeon if stoma is dark red, purplish, or black, dry, continuous/ heavy bleeding, or breakdown in the suture line securing stoma to abdominal wall.
A client is experiencing pain and nausea related to biliary colic. Which statement should the nurse make to manage this client's symptoms? (Select all that apply.) A. "Intravenous fluids will ensure that you are well hydrated." B. "It's important for you to be comfortable so that you can rest." C. "A bland diet helps with nausea." D. "Pain medication will be prescribed." E. "Medication will help with the nausea and vomiting."
abcd Clinical therapies for treating biliary colic include administering analgesics, getting adequate rest, correcting fluid and electrolyte imbalances, and administering antiemetics.
A client is recovering from a laparoscopic cholecystectomy. Which nursing action should the nurse use to reduce this client's risk of infection? (Select all that apply.) A. Administer antibiotics as prescribed. B. Assess the abdomen every 4 hours. C. Monitor vital signs, including temperature, every 4 hours. D. Coach to take deep breaths every 1-2 hours while awake. E. Place in Fowler position.
ABCD To reduce the risk of infection, the nurse will monitor vital signs, including temperature, every 4 hours, because changes may be the first sign of infection. Assessment of the abdomen can reveal signs of a surgical wound infection. Turning, breathing, and incentive spirometry help prevent postsurgical atelectasis and subsequent pneumonia. Antibiotics are used to control infection. Fowler position may enhance the client's comfort but will have no effect on postsurgical infection.
An adolescent is experiencing right upper quadrant abdominal pain, nausea, and vomiting after eating at a fast food restaurant. Which treatment should the nurse anticipate to be prescribed for this patient? ANSWER Emergency laparoscopic surgery Intravenous fluids, antiemetics, and analgesics Oral dissolution therapy Intravenous antibiotic therapy
Intravenous fluids, antiemetics, and analgesics The clinical therapies indicated for treating episodes of biliary colic include administering antiemetics and analgesics, providing adequate rest and nutrition, and correcting electrolyte imbalances. Treatment is usually symptomatic, so surgical intervention or oral dissolution therapy is not necessary at this time. There is no acute infection, so IV antibiotics are not required.
The nurse notes that a patient is prescribed a serum bilirubin level. Which symptom should the nurse expect to assess in this patient? ANSWER Jaundice of the skin and sclera of the eyes Pain in the left shoulder that radiates to the back Pain in the lower right quadrant Dark, tar-colored stools
Jaundice of the skin and sclera of the eyes Serum bilirubin evaluates obstructed bile in the biliary duct. A patient would experience jaundice, pain in the upper right quadrant and right scapula, and nausea. Stools would be light in color, not dark or tar colored. (extra; An oral cholecystogram is performed with a dye administered orally. It can assess the gallbladder's ability to concentrate and excrete bile)
A client with cholelithiasis is not a surgical candidate at this time. Which pharmacologic treatment should the nurse expect to be prescribed for this client? (Select all that apply.) A. Cholestyramine B. Antipyretics C. Antibiotics D. Ursodiol E. Chenodiol
acde Pharmacologic treatment for gallstones is used for clients who refuse surgery or for whom surgery is contraindicated. Medications used in the treatment of gallstones include ursodiol, chenodiol, antibiotics, cholestyramine, and opioid analgesics. Antipyretics are a pharmacologic treatment for fever, not cholelithiasis itself. (extra; Ursodiol is a bile acid. It is used to dissolve gallstones in clients who cannot have surgery to remove gallstones. Ursodiol is also used to prevent the formation of gallstones in clients who are overweight or who are losing weight very quickly. It works by decreasing the production of cholesterol and by dissolving the cholesterol in bile so that it cannot form stones. Ursodiol is generally well tolerated but can cause diarrhea or constipation.)
The nurse is planning an educational program about development and prevention of gallstones for a community group. Which population should the nurse identify to be most at risk for developing gallstones? A. African American clients B. Women over the age of 40 C. Middle-aged Caucasian American men D. Young adult Asian American women
b Genetic considerations and risk factors vary depending on the nature of the inflammatory disorder. Female sex, being over the age of 40, American Indians, and Mexican Americans are most at risk for gallstones. Family history is also associated with increased risk.
The nurse is providing dietary teaching to a client with a history of gallstones. Which diet should the nurse recommend? (Select all that apply.) A. Low sodium B. Low fat C. High carbohydrate D. High vitamin C E. High protein
be A low-carbohydrate, low-fat, high-protein diet reduces symptoms of cholecystitis.
A client who is morbidly obese is diagnosed with acute cholelithiasis. Which nonpharmacologic therapy should the nurse expect to be prescribed for this client? A. Fat-soluble vitamins B. Bile salts C. Withholding all oral intakes and inserting a nasogastric tube D. Parenteral nutrition
c During an acute attack of cholecystitis, food should be eliminated and a nasogastric tube inserted to relieve nausea and vomiting. Parenteral nutrition is not indicated at this time. Once the client is eating again, dietary fat intake may be limited, especially if the client is obese. If bile flow is obstructed, fat-soluble vitamins (A, D, E, and K) and bile salts may need to be administered but this would be considered a pharmacologic therapy.
lifespan consideration regarding cholecystitis
children -Patients with sickle cell disease and biliary abnormality ▪Often require cholecystectomy ▪May experience complications pregnant woman: -Most common cause for hospitalization in first year postpartum. the more pregnancies and greater age at pregnancy= more at risk •Older adults -Adults with variant ABCG8-D19H more likely to have gallstone recurrence -No relationship noted between abnormal lipid profiles and gallbladder disease -Biliary dyskinesia (abnormal movement of gallbladder)common cause of surgical intervention
nursing process on cholecystitis
•Observation and patient interview -Current manifestations -Duration of symptoms -Risk factors or previous history -Chronic diseases -Diet -Use of oral contraceptives or possibility of pregnancy •Physical assessment -Weight -Color of skin, sclera -Abdominal tenderness -Color of urine, stool •Goals may include that patient will -Demonstrate no signs or symptoms of infection -Report adequate pain control -Demonstrate understanding of low-fat diet with adequate intake of fat-soluble vitamins -Verbalize awareness of symptoms to report immediately to healthcare provider •Care for postoperative patient -Monitor vital signs every 4 hours -Assist with coughing, deep breathing, incentive spirometry -Place in Fowler position, encourage ambulation -Administer antibiotics as ordered -Refer to dietitian, nutritionist for diet counseling -Help patient learn to manage dietary restrictions -Administer vitamin supplements as ordered -assess T-tube, connected, monitor drainage > 500 mL in first 24 hours is excessive and should be reported;
colon resection
Colon Resection: removal of part of the colon (cut at the ends where the intestine is healthy) and regional lymph nodes. -if no bowel obstruction or perforation, possible to do laparoscopic colon resection, which will have the advantages of: small incisions, minimal blood loss and postop pain, pt may eat and ambulate sooner than with laparotomy resection. -reasons for Colon resection: due to presence of tumors, adhesions, diverticulitis, intestinal infarction, embolectomy, thrombectomy, gangrenous colon, ulcerative colitis, Chron's disease, and other conditions affecting the GI tract. anastomosis= reattaching two ends (this is the usual procedure for colon resection); however if not possible/feasible, an ostomy must be made (name depends on location of it) colectomy (surgical removal of entire colon) with colostomy (either permanent or temporary)- surgical creation of an opening (stoma) of the colon onto the surface of the abdomen to allow passage of stool. Colon resection can be performed via laparoscopy for shorter hospital stays, less pain, fewer complications, and quicker recovery than open.
gallbladder disease
•Altered bile flow through hepatic, cystic, common bile duct (CBD) is a common problem •Cholelithiasis is formation of stones/gallstones in gallbladder or biliary duct system •Gallstones: - Most form in gallbladder, then -migrate into ducts causing cholangitis(inflammation of the bile duct) •Obstruction of ducts may cause biliary colic. characterized by Severe, steady pain In the epigastric region or right upper quadrant (RUQ). the pain May radiate to back, right scapula, or shoulder. symptoms of cholelithiasis: (symptoms are more local) ▪Abrupt onset Severe, steady pain that is Localized to epigastrium and RUQ ▪pain May radiate to back, right scapula, shoulder ▪Lasts 30 minutes to 5 hours ▪Nausea ▪Vomiting •Cholecystitis -is the Inflammation of gallbladder -Acute cholecystitis: occurs after stone obstructs cystic duct ▪Begins with attack of biliary colic ▪Pain lasts longer than the colic, about 12-18 hours. -its symptoms are: ▪Anorexia, nausea, vomiting ▪RUQ tenderness and guarding ▪Chills and fever -Chronic cholecystitis is caused by: ▪Repeated bouts(attacks) of acute cholecystitis due to Persistent irritation of gallbladder wall by stones -complications of cholecystitis: ▪Empyema(collection of pus and fluids in gallbladder) ▪Gangrene, perforation of duct which can lead to peritonitis or abscess formation(if pus with bacteria moves to peritoneum, it will cause infection) ▪Formation of fistula into adjacent organ(gallbladder and other organ, such as intestines get joined/fused together) ▪Gallstone ileus (is obstruction of the intestine by stones that travel from gallbladder to intestine/ilium via a perforation or fistula) Risk factors for developing cholecystitis: •Age (older 40+) •Family history (of gallstones) •Race or ethnicity -Native Americans, Hispanics of Mexican descent •Obesity dyslipidemia ((having too much cholesterol in the bile and in general.) •Rapid weight loss •Being female •Biliary stasis (when bile flow is slow due to age, infection, etc) symptoms of cholecystitis: (symptoms are more systemic) ▪Abrupt onset, severe, steady, pain that lasts 12-18 hours ▪pain is Generalized in RUQ; may radiate to back, right scapula, shoulder ▪pain is Aggravated by movement, breathing ▪Anorexia, nausea, vomiting ▪RUQ tenderness and guarding ▪Chills and fever Diagnostic tests: •Serum bilirubin (elevated means bile duct obstruction) •Complete blood count (CBC) (for infection) •Serum amylase and lipase (to ruleout pancreatitis due to obstruction of common bile duct which stops enzymes flow from pancreas to small intestine) •Abdominal x-ray, ultrasound of gallbladder •Oral cholecystogram (better than ct scan) •Gallbladder scan
The nurse teaches a patient about caring for a T-tube after having surgery to remove the gallbladder. Which information should the nurse provide the patient before discharge? ANSWER "If you see any drainage, let the surgeon know right away." "You will see less drainage each day, until the duct fully heals." "In the beginning, your drainage will be dark green, then it will become dark yellow." "If the drainage stops, milk the tube toward the puncture wound."
"You will see less drainage each day, until the duct fully heals." As healing occurs from the bile duct, bile drains from the tube; the amount of bile should decrease. Teach the patient to expect brown-green drainage and to notify the healthcare provider if drainage stops. Drainage is always expected, so there is no need to notify the surgeon if it is seen. The drainage will not turn yellow. The T-tube should never be milked to encourage drainage. (Biliary stasis(slow emptying of bladder) usually occurs during pregnancy due to hormonal changes. when bladder empties slow, it allows for cholesterol to accumulate and form stones/cholelithiasis)
extras
(extra: Cholestyramine is used for severe jaundice and accumulation of bile salts on the skin. An opioid would be used for pain relief. Chenodiol and ursodiol reduce cholesterol production) (extra; The ultrasound of the gallbladder shows the presence of gallstones and gallbladder emptying, so is useful to diagnose cholelithiasis. An x-ray just shows the presence of gallstones. Serum amylase and lipase would indicate possible pancreatitis.) (extra; Biliary dyskinesia is a motility disorder that affects the gallbladder. It is usually a symptom of a disease such as cholecystitis, gallstones, or pancreatitis, rather than being a disease itself.) (extra; Pale or clay-colored stools indicate a problem with the drainage of the biliary system(common bile duct or other duct used for bile). Bile salts are released into the stools by the liver, giving the stools a brown color) (extra; Serum amylase and lipase are measured to identify possible pancreatitis related to common duct obstruction. Elevated direct (conjugated) bilirubin levels may indicate obstructed bile flow in the biliary duct system. elevated indirect (unconjugated) bilirubin level may indicate a rise in red blood cell hemolysis/ sickle cell disease)
A patient experiences severe nausea and vomiting caused by acute cholecystitis. Which nonpharmacologic intervention should the nurse implement first? ANSWER Limit dietary fat intake. Administer bile salts. Provide foods high in fat-soluble vitamins. Hold all oral intake.
Hold all oral intake. Food intake is eliminated during an acute attack of cholecystitis. A nasogastric tube is prescribed and inserted to relieve nausea and vomiting. Dietary fat intake may be limited, especially if the patient is obese. If bile flow is obstructed, fat-soluble vitamins (A, D, E, and K) and bile salts may need to be administered.
A client with acute cholecystitis is experiencing nausea and vomiting. Which nursing action should the nurse use to address this client's nutritional status? (Select all that apply.) A. Reviewing serum electrolytes B. Administering antiemetics as prescribed C. Assessing height and weight D. Advising to consume a low-protein diet E. Counseling regarding low-fat menu choices
abce Assessing height and weight, reviewing serum electrolytes, counseling on low-fat menu choices, and administering antiemetics as prescribed are all nursing actions that address the client's nutritional status. A high-protein, not low-protein, diet is used to treat cholecystitis.
A client with right upper quadrant abdominal pain asks why so many tests are being scheduled. Which is the reason that the nurse should give to this client? (Select all that apply.) A. To determine if gallstones are present B. To determine the location of gallstones C. To diagnose the disorder D. To prevent recurrence E. To identify possible complications
abce Diagnostic tests are used to identify the presence and location of gallstones, identify possible complications of the gallstones, and help differentiate gallbladder disorders from other disease processes. Diagnostic tests do not prevent the formation of gallstones but can give information necessary for treatments that prevent recurrence.
A pregnant client of American Indian heritage experiences mild gastric distress and nausea after eating large meals and constant sharp abdominal pain. Which additional information should the nurse collect during the interview? (Select all that apply.) A. Current diet B. Length of time the symptoms last and when they occur C. History of chronic diseases D. Smoking history E. Expected due date F. Other symptoms
abcf The nurse should note current manifestations, including right upper quadrant (RUQ) abdominal pain, and its character and relationship to meals, duration, and radiation; nausea and vomiting; other symptoms; duration of symptoms; risk factors or previous history of symptoms; chronic diseases such as diabetes, cirrhosis, or IBD; current diet; and use of oral contraceptives or possibility of pregnancy
The nurse is preparing health promotion teaching for a client with gallbladder disease. Which topic should the nurse include in the teaching session? (Select all that apply.) A. Importance of a high-fiber diet B. Role of a high-cholesterol diet on gallstone formation C. Role of hypolipidemia on gallstone formation D. Dangers of rapid weight loss E. Importance of a low-cholesterol diet
abde Clients should be taught about the role of obesity, hyperlipidemia, and a high-cholesterol diet on gallstone formation; the importance of a high-fiber, low-fat, and low-cholesterol diet to reduce the incidence of gallbladder disorders; and the dangers of rapid weight loss. (extra; A balanced diet and exercise (at least 20 min, 3 times per week) will help keep the client's weight within normal limits)
A middle-aged female client who is obese has been experiencing right upper quadrant abdominal pain for the past several hours. For which risk factors of gallstone development should the nurse assess this client during the health history? (Select all that apply.) A. Inflammation of the gallbladder B. Biliary colic C. Excess cholesterol D. Biliary stasis E. Abnormal bile composition
acde : The formation of gallstones occurs when several factors are present, including abnormal bile composition, biliary stasis, inflammation of the gallbladder, and excess cholesterol. Excess cholesterol in bile is associated with obesity, a high-calorie and high-cholesterol diet, and drugs that lower serum cholesterol levels. Biliary colic is the pain described in cholelithiasis. This pain is localized to the epigastrium and the right upper quadrant of the abdomen. Biliary colic does not lead to the formation of gallstones.
A client asks what causes gallstones to form. Which factor should the nurse explain as being present when these stones are formed? (Select all that apply.) A. Abnormal bile composition B. Rapid weight gain C. Inflammation of the gallbladder D. Biliary stasis E. Excess cholesterol
acde Gallstones are formed due to abnormal bile composition, an inflammation of the gallbladder, biliary stasis, and excess cholesterol. Rapid weight loss, not weight gain, is a factor that contributes to the formation of gallstones (extra; risk factors for gallstones: Rapid weight loss, family history of gallstones, American Indian ethnicity, obesity, hyperlipidemia, female sex, pregnancy, diabetes mellitus, cirrhosis, ileal disease, and sickle cell disease)
A client with acute cholecystitis is experiencing jaundice. Which should the nurse consider as the reason for the jaundice? A. Accumulation of fat in the wall of the gallbladder B. Obstruction of the cystic duct by a gallstone C. Accumulation of bile in the hepatic duct D. Viral infection of the gallbladder
b When acute cholecystitis is accompanied by jaundice, partial common duct obstruction is likely, which is usually due to stones or inflammation.
The nurse prepares discharge teaching for a client recovering from a cholecystectomy. Which topic should the nurse include in this teaching? (Select all that apply.) A. High-fat diet B. Activity level C. Surgical incision care D. Pain control measures E. Manifestations of postoperative complications
bcde The nurse will instruct the client on the prescribed activity level, manifestations of postoperative complications that must be reported to the healthcare provider, pain control measures, and surgical incision care. A low-fat diet
A client is experiencing severe upper abdominal pain and jaundice. Which finding on the cholescintigraphy should indicate to the nurse that the client has cholelithiasis? A. Viral infection of the gallbladder B. Accumulation of bile in the hepatic duct C. Obstruction of the cystic duct by a gallstone D. Accumulation of fat in the wall of the gallbladder
c Cholelithiasis is almost always caused by a gallstone lodged in the cystic duct. Accumulation of bile in the hepatic duct would not lead to cholecystitis. Neither the accumulation of fat nor a viral infection leads to cholecystitis.
The nurse evaluates a client's understanding of discharge teaching following a laparoscopic cholecystectomy. Which client statement indicates teaching has been effective? A. "I will increase the protein in my diet by drinking whole milk." B. "I can have some hot chocolate with my breakfast." C. "I will be sure to get up and walk every hour." D. "I will take my pain medicine on an empty stomach to get the maximum benefit."
c Clients from a laparoscopic cholecystectomy are often treated in day surgery, but discharge instructions should be similar to those for other clients who have had abdominal surgery. Therefore, they should be informed to be sure to increase their activity level when they return home. Clients should take pain medications with food to diminish irritation to the stomach lining. The client should follow a diet low in fat and high in fat-soluble vitamins. Therefore, including hot chocolate and whole milk would not be appropriate food choices.
surgery for cholecystitis
•Laparoscopic cholecystectomy -Treatment of choice -Minimally invasive -usually 4 incisions. may have t-tube, which needs to be connect to steril container/collection baf that needs to be below level of bile duct. report to MD if drainage >500ml in the first 24 hours. -Low risk of complications -Hospital stay of <24 hours -Not all patients are candidates -Risk that the surgery may be converted to laparotomy(open surgery/ open cole/ open cholecystectomy) during the procedure -postop pt my experience shoulder pain (phrenic nerve irritation from CO2) , it will disappear after CO2 is absorbed. •Cholecystectomy with CBD(common bile duct) exploration -When stones are lodged in ducts, a T-tube to maintain patency/flow of duct, promote bile passage -Patients who are at surgical risks may opt for Cholecystostomy to drain gallbladder(putting a drain tube in the gallbladder) -Choledochostomy ▪Remove stones ▪Position T-tube in CBD (common bile duct) •Shock wave lithotripsy -To dissolve large gallstones -Used with drug therapy •Percutaneous cholecystostomy -Ultrasound-guided drainage of gallbladder -Used for high-risk patients *pharm and nonpharm therapy: -for pt who can get surgery, used drugs to dissolve gallstones. process may take up to 2 year. -to not use drugs, if pt has acute pain, eliminate food intake and put a nasalgastric tube, limit fat intake, if bile duct is obstructed, administer fat soluble vitamins(adek)