Choleycystitis Key points - PowerPoint Presentation

Slide1

Choleycystitis

Key points

Cholecystitis

is an inflammation of the gallbladder wall. The “attack”

usually subsides

in 2 to 3 days.

Bile

is used for the digestion of fats. It is produced in the liver and stored in

the gall

bladder.

Cholecystitis

can be acute or chronic, and it can also obstruct the pancreatic duct

.

Cholecystitis

is most often caused by gallstone (

cholelithiasis

) obstructing the cystic and/or common bile ducts (bile flow from gallbladder to duodenum);

cholecystitis

without gallstones is rare and serious.

Key points

C

alculi

usually form in the

gallbladder from

solid constituents of bile and vary greatly

in: size, shape

, and composition.

There

are two major types of gallstones:

pigment stones, which contain an excess of unconjugated

pigments

in the bile,

and

cholesterol

stones (the

more common

form), which result from bile supersaturated

with cholesterol

due to increased synthesis of cholesterol

and decreased

synthesis of bile acids that dissolve cholesterol.

Key points

Most

clients

with

cholecystitis

have

gallstones (

calculous

cholecystitis

). A

gallstone obstructs

bile outflow and bile in the gallbladder initiates

a chemical

reaction, resulting in edema, compromise of the

vascular supply

, and gangrene.

C

holecystitis

(

acalculous

???)

may occur after surgery, severe trauma,

or

burns,

cystic duct obstruction, multiple

blood transfusions

, and primary bacterial infections of the

gallbladder.

Infection

causes pain, tenderness,

and rigidity

of

the

RUQ

and is associated with

N & V and

the

usual signs of

inflammation

.

Purulent

fluid

indicates

an

empyema

Risk Factors

More

common in females

Obesity

(impaired fat metabolism, high cholesterol levels

)

Multiparus

Older

than

40

years of age (more likely to develop gallstones

) 4Fs

High-fat

diet

Pills; estrogen

Genetic

predisposition

Individuals with type 1 diabetes mellitus (high triglycerides)

Low-calorie, liquid protein diets

Rapid weight loss (increases cholesterol)

Risk Factors

Risk factors

for pigment stones

include:

cirrhosis

,

hemolysis, and

infections of the biliary tract.

These

stones cannot be

dissolved and

must be removed surgically.

Triggering Factors

Trauma

Surgery

Coronary events

Diabetes

Fasting

Immobility

Hormone replacement therapy (HRT)

Pregnancy

Diagnostic Procedures and Nursing Interventions

RUQ US

is the most diagnostic.

Visualizes gallbladder

edema

.

Cholecystogram

,

cholangiogram

; celiac axis arteriography

Abdominal x-ray (may visualize calcified gallstones)

WBCs elevations

Direct

(normal is 0.1 to 0.3 mg/

dL

), indirect (0.2 to 0.8 mg/

dL

), and total (0.1

to 1.0

mg/

dL

) serum bilirubin levels (elevated if obstruction)

Aspartate aminotransferase (AST) and lactate dehydrogenase (LDH) (elevated

if liver

dysfunction)

Serum cholesterol (elevated above 200 mg/

dL

)

Hepatobiliary

scan (assesses patency of biliary duct system)

Therapeutic Procedures and Nursing Interventions

Medical Management

Major objectives of medical therapy are to reduce the

incidence of

acute episodes of gallbladder pain and

cholecystitis

by:

supportive and dietary management and, if possible,

remove the cause by pharmacotherapy, endoscopic

procedures, or

surgical intervention.

Therapeutic Procedures and Nursing Interventions

Cholecystectomy

–

with a laparoscopic or an open

approach

(when exploration of biliary ducts is

indicated

).

Postoperatively, clients may experience free air pain following

laparoscopic surgery

.

Ambulation is helpful.

Following an open approach, nursing care includes monitoring drainage

from inserted

Jackson-Pratt (JP) drains and T-tube.

Therapeutic Procedures and Nursing Interventions

Nonsurgical Removal of Gallstones

In addition to dissolving gallstones, they can be removed

by other

instrumentation (

eg

, catheter and instrument with

a

basket

attached are threaded through the T-tube

tract

or

fistula formed

at the time of T-tube insertion,

ERCP

endoscope),

intracorporeal

lithotripsy (laser

pulse

), or

extracorporeal shock wave

therapy(lithotripsy

or

extracorporeal

shock

wave lithotripsy

[

ESWL]).

Assessments

May be silent, producing no pain and only mild GI symptoms

May be acute or chronic with

epigastric

distress (

fullness, abdominal

distention, and vague

URQ); may

follow a meal rich in fried or fatty foods

An

attack of

cholecystitis

“gallbladder attack

”

is characterized by:

Sharp pain in the

RUQ of

the abdomen, often radiating

to the RT

shoulder.

Pain with deep inspiration during right subcostal palpation (

Murphy’s sign

).

Intense pain

(tachycardia,

pallor, diaphoresis) after ingestion of

a large

quantity of high-fat food.

Assessments

Rebound tenderness.

Nausea, anorexia, and vomiting.

Dyspepsia, eructation (belching), and flatulence.

Fever

Jaundice, clay-colored stools, dark urine,

steatorrhea

(fatty stools), and

pruritus may

be seen in clients with chronic

cholecystitis

(due to biliary obstruction

).

Deficiencies of vitamins A, D, E, and K (fat-soluble vitamins)

NANDA Nursing Diagnoses

Acute

pain

Impaired gas exchange

Risk for

infection

Impaired skin

integrity

Imbalanced nutrition, less than body requirements,

Deficient

knowledge

Nursing Interventions

Achieve remission with rest, IV fluids, nasogastric

suction, analgesia

, and antibiotics

.

Dietary

Counseling

Encourage a low-fat diet (reduced dairy; avoid fried foods, eggs, cream,

chocolate

, cheese, rich dressings,

nuts, and

gravies

).

high protein and carbohydrates

Promote weight reduction.

Fat-soluble vitamins and bile salts may be prescribed if obstruction

is present

to enhance absorption and aid digestion.

Avoid gas-forming foods (beans, cabbage, cauliflower, broccoli).

Smaller, more frequent meals may be tolerated

better

Nursing Interventions

Administer analgesics as needed and

prescribed

Meperidine

(Demerol) is generally preferred over

morphine)

Antispasmodics and

anticholinergics

Antiemetics

Postoperative Care

Support pain management.

Encourage splinting to reduce pain.

Encourage measures to reduce risk of respiratory complications

Monitor

wound incision(s) and provide wound care.

Monitor and record T-tube drainage (initially bloody, then

greenbrown

bile

).

Initially, may drain > 400 mL/day and then gradually decreases

in amount

.

Nursing Interventions

Report sudden increases in drainage or amounts

exceeding 1,000

mL/day.

Inspect surrounding skin.

Maintain flow by gravity.

Clamp 1 to 2

hr

ac and pc.

Monitor and document the client’s response to food.

Client Education

Activity precautions 4 to 6 weeks

Care of T-tube (up to 6 weeks postoperatively) – Report sudden

increase in

drainage or foul odor; Clamp 1 to 2

hr

before and after meals.

Stool color should return to brown color in about a week.

Encourage a low-fat diet.

Surgical Terms

Laparoscopic cholecystectomy: performed through a small

incision

or puncture made through the abdominal wall in

the

umbilicus.

Cholecystectomy

: Gallbladder is removed through an

abdominal

incision (usually right subcostal) after ligation of

the

cystic duct and artery.

Minicholecystectomy

: Gallbladder is removed through a

small

incision.

Choledochostomy

: incision into the common duct for stone

removal

.

Cholecystostomy

(surgical or percutaneous): Gallbladder is

opened

, and the stone, bile, or purulent drainage is removed.

Complications and Nursing Implications

Obstruction

of the bile duct can cause ischemia and a rupture of the

gallbladder wall

is possible.

Rupture

of the gallbladder wall can cause a local abscess

or peritonitis

(rigid, board-like abdomen, guarding), which requires

surgical intervention

and administration of broad spectrum antibiotics.