NUR 3180 – Primary Concepts of Adult Nursing Study Guide - Exam 3

1. Cholecystitis: acute versus chronic, causes, symptoms, consequences, diagnostic studies, dietary, medical, nursing interventions, nursing process (assessment, diagnosis, planning, intervention, evaluation). Cholecystitis Pg. 1391 - Inflammation of the gallbladder, which can be acute or chronic causes pain, tenderness and rigidity of the upper right abdomen that may radiate to the mid-sternal area or right shoulder. - Associated with nausea, vomiting, and the usual signs of acute inflammation. - In Calculous Cholecystitis, a gallbladder stone obstructs bile outflow. Cholelithiasis - Calculi, or gallstones usually form in the gallbladder from the solid constituents of bile; vary in size, shape, and composition. - Uncommon in children and young adults, increase with age. Pathophysiology - There are two types of gallstones: those composed of pigment (Pigment stones) and those composed of cholesterol (Cholesterol stones). - Pigment stones form when unconjugated pigments in the bile precipitate to form stones. - The risk of developing such stones in increased in patients with cirrhosis, hemolysis, and infections of the biliary tract. Cannot be dissolved and must be removed surgically. - Cholesterol stones account for most of the remaining 75% of cases of gallbladder disease in the US. Cholesterol a normal constituent of bile, is insoluble in water. Its solubility depends on bile acids and lecithin (phospholipids) in bile - affected women are older than 40 years, multiparous, and obese. Risk Factors - Increased age - Female, especially those who have had multiple pregnancies or who are of Native America or U.S. southwestern Hispanic ethnicity. - Family history - Overweight - Frequent changes in weight or Rapid weight loss diets - Treatment with high-dose estrogen (in prostate cancer). - Low-dose estrogen therapy- carries a small increase in the risk of gallstones. - Ilear resction of disease, and contraceptives use - Cystic fibrosis and diabetes. Manifestations - Gallstones are silent, producing no pain and only mild GI symptoms. Epigastric Distress - Fullness, abdominal distention, vague upper right quadrant pain of the abdomen after eating a meal rich in fried or fatty foods. Infection - Fever, palpable abdominal mass Pain and Biliary colic - If a gallstone obstructs the cystic duct, the gallbladder becomes distended, inflamed, and eventually infected (acute cholecystitis). - Infection- Patient develops a fever, and may have a palpable abdominal mass - Patient may have biliary colic with excruciating upper right abdominal pain that radiates to the back or right shoulder. Biliary colic is associated with nausea and vomiting, noticeable several hours after a heavy meal. Jaundice - Blockage of the common bile duct. - Jaundice and accumulation of bile salts causes the pruritus of the skin. Changes in Urine and Stool Color - Excretion of bile pigments by the kidneys gives the urine a dark color. - Feces, no longer colored with bile pigments, are grayish (like putty) or clay colored. Vitamin Deficiency (ADEK) - Obstruction of bile flow interferes with absorption of the fat-soluble vitamins Assessment and Diagnostic Findings - The nurse should educate the patient about the purpose, what to expect Abdominal X-Ray Ultrasonography - Show size of abdominal organs and presence of masses. - Most accurate if patient fasts overnight so that the gallbladder is distended. Radionuclide Imaging or Cholescintigraphy - Radioactive agent is administered IV Cholecystography Endoscopic Retrograde cholangiopancreatography (ERCP) - Permits direct visualization of structures that previously could be seen only during laparotomy. - Fiber optic scope - Esophagus to descending duodenum - Fluoroscopy utilized - Extraction of gallstones Medical Management - Major objectives are to reduce the incidence of acute episodes of gallabladder. - Removal of the gallbladder (cholecystectomy) Nutritional and Supportive Therapy - Remission is achieved with rest, IV fluids, nasogastric suction, analgesia, and antibiotic agents. - Diet after an episode is low-fat liquids. These include powdered supplements high in protein and carbohydrate stirred into skim milk. Cooked fruits, rice or tapioca, lean meats, mashed potatoes, non-gas-forming vegetables, bread, coffee, or tea. - Patient should avoid eggs, cream, pork, fried foods, cheese, rich dressings, gas-forming vegetables, and alcohol. Preoperative Measures - Chest x-ray, electrocardiogram, and liver function tests, in addition to x-ray studies of the gallbladder. - Administration of vitamin K if the prothrombin level is low. - Postoperative pneumonia and atelectasis can be avoided by deep breathing - Patient should be informed that drainage tubes and NG tube and suction might be required postoperative period if an open cholecystectomy is performed. Laparoscopic cholecystectomy - Patient is educated that an open abdominal procedure may be necessary, and general anesthesia is administered. - Performed through a small incision or puncture made through the abdominal wall at the umbilicus. - Abdomen is insufflated with CO2 to assist in inserting the laparoscipe and to aid in visualizing the abdominal structures; - Best nursing intervention after this procedure is to promote ambulation to get rid of gas. Cholecystectomy (Open, traditional) - Surgical removal of gallbladder through an abdominal incision in right upper quadrant after the cystic duct and artery are ligated. Nursing Process The Patient Undergoing Surgery for Gallbladder Disease Assessment - Education on the need to avoid smoking, to enhance pulmonary recovery postop; and to avoid respiratory complications. Also, the need to avoid aspirin. - Assessment focuses on the patient’s respiratory status. - Nurse notes a history o