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Introduction of case scenario Pathophysiology, predisposing factors and clinical manifestations of cholecystitis Clinical assessments and diagnostic tests

ts Pre and post-operative nursing care Follow up care Discharge teaching plan

Case Scenario
O Ms Olivia

O 42 years old
O Single, stays with parents O Sales assistant O Non-smoker/drinker O Intense pain in the right upper quadrant

of her abdomen which radiated to both shoulders O Diagnosed with cholecystitis O Open cholecystectomy with exploration of the bile duct

Pathophysiology Predisposing factors & Clinical manifestation Cholecystitis

Cholecystitis
By definition, cholecystitis is an inflammation of the gallbladder. (Canobbio, 2006) Is the most common problem resulting from gallbladder stones. Can be classified as acute or chronic.
Gallbladder Abdominal
wall

Epidemiology
Gallstones are usually found in individuals older than 40 years, with high incidence in people of Pima and Chippewa descent, white women, and African Americans. (Rothrock & Alexander, 2012)

More than 90% of acute cholecystitis are associated with gallstones. About 60% of patients with acute cholecystitis are women, and tends to be more severe in men. (Strasberg, 2008)

ACUTE CHOLECYSTITIS
Obstruction of the neck of the gallbladder or cystic duct caused by stones impacted in Hartmann's pouch Direct pressure of the calculus on the mucosa Ischemia, necrosis, and ulceration with swelling, edema, and impairment of venous return. Increase and extend the intensity of the inflammation.

Stages of Acute Cholecystitis

-Gallbladder has a grayish appearance & is edematous.

-There is an obstruction of the cystic duct and the gallbladder begins to swell.
- It no longer has the "robin egg blue" appearance of a normal gallbladder.
- As

acute cholecystitis progresses, the gallbladder begins to become necrotic and gets a speckled appearance as the wall begins to die.
- Gallbladder undergoes gangrenous

change and the wall becomes very dark green or black. - This is the stage when perforation occurs.

10

Predisposing Factors
Female >40 yrs Obese Diabetes Liver disease Pancreatitis Cancer of gallbladder Strictures of bile duct High fat, high calorie diet In women, estrogen levels, hormone replacement therapy

Clinical Features

Complications
Cholangitis Biliary colic Jaundice Empyema Liver abscess Pancreatitis. Peritonitis Carcinoma Fistula formation Gall stone ileus.

Gallstone ileus

Specific clinical assessments and diagnostic tests

Chief complaint
Intense pain in the right upper quadrant of her abdomen which radiated to both shoulders.

Physical Assessment
General Condition Alert and orientated.

Weight:
BMI:

65kg

29

Vital signs:
Temp 37.8C PR 80/min RR 20/min BP 130/74 mmHg Pain Score 4

Abdomen is soft but slightly tender. Skin is dry with slightly jaundice.

Murphys sign
Palpation of right upper quadrant marked tenderness and inability to take deep breath.

Laboratory Test (Pre-op)


Type
WBC

Results
12,000 uL

Normal range
4,500 11,000 uL 0.3 1.0 mg/dL

Serum bilirubin (total) Serum amylase

2.0 mg/dL

180 U/L

40 140 U/L

Radiology Test
Gallbladder ultrasound: Gall stones in the gall bladder and the common bile duct Gallbladder scan: Cystic duct obstructions

Treatment

Surgical Intervention

Open Cholecystectomy
or Laparoscopic Cholecystectomy
removal of the gallbladder.

Pre-operative nursing care teaching

Before your surgery:


Informed consent A consent form is a legal document that explains the tests, treatments, or procedures that you may need. Informed consent means you understand what will be done and can make decisions about what you want. Medications to avoid

Aspirin, ibuprofen, vitamin E, warfarin (Coumadin), and any other drugs that can alter coagulation & other bio-chemical processes

Pre-op medications Anti hypertensive drugs Anti anxiety drugs Anti emetic drugs Prophylactic antibiotics reduces the incidence of surgical wound infection

Take a baseline of vital signs & monitor them before going to OT

Blood tests (LFT, FBC, PT/PTT, Group & Cross match) X-rays, ECG &Ultrasound of the gallbladder

Bowel prep
You may need to have an enema before your surgery. This liquid is placed into your rectum to flush stool out of your intestines

Skin prep
Operative site is cleansed, shaved or marked.

NBM
You may drink a sip of water with your medications, but avoid eating and drinking at least six hours before your surgery.

I/V line
An I/V (intravenous) is a small tube placed in your vein that is used to give you medicine or liquids.

Pain Management
Pain score should be introduced & explained to the patient

Post-operative exercises
Teach post-operative exercises ,for example, turning, deep breathing & coughing.

Prostheses
Ask the patient to remove his dentures, contact lenses, and artificial limbs.

Jewellery
It should be removed for safekeeping.

Personal hygiene
Assist the patient with personal hygiene Bathe or shower. Remove nail polish and make-up. Mouth care.

Offer emotional support


Answer questions concerning surgery. Provide explanation of each preoperative nursing measure. Ask the patient about spiritual needs. Provide family members with information

Post-0perative Nursing Care

Post-op care Open cholecystectomy Recovery phase: 4-6weeks

Airway

Maintain airway patency


- Perform oral-pharyngeal suctioning PRN

Breathing

- Breathing sound, rate, rhythm, SpO2 level - Oxygen therapy

Body temperature

Conscious level

- Ability to follow commands, move extremities - Muscle strength and sensation

Cardiac & circulation - Vital signs (Hourly)


- Assess skin colour, & condition -Check for hemorrhage (drainage & dressing) - Ted stocking/ calf compressor

Comfort level
- Pain:
- Pain score - Administer analgesic as prescribed - Hourly PCA monitoring - Incentive spirometer - Diaphragmatic breathing

- Nausea & vomiting:


- Administer anti emetic as prescribed - Monitor for fluid/electrolyte imbalance

- Hygiene:
- Sponging on POD 1,2 - Maintain oral hygiene & offer ice chips

Drip

- Monitor type, amount & flow rate - Ensure patency - Observe for phlebitis Dressing & Drainage Wound dressing Urinary catheter care T-tube care NGT suction

E F

Ensure safety File (Documentation)

- Check POT for detail information of surgery and note special instructions

H N

Hydration

- Monitor intake & output

Nutrition

- Check NBM (resume feeds when bowel sounds presence) Clear liquids only at first. Start slowly.

Post-operative exercises

- Diaphragmatic breathing - Controlled coughing

Psychological support
- Anxiety of patient and family Offer psychological support & reassurance Keep patient & family informed of progress

Nasogastric tube
For food & medicine if NBM or attach to the suction for
Draining out of gastric fluids contents, & decompression of intestinal tract.

NGT care
Manual aspiration ( before that, check placement of tubing in the stomach) -4 hourly OR Using intermittent suction unit (ISU)-The tube may be attached to suction (vacuum) to keep your stomach empty. Tube not kinked Secured well Ensure patency and document COCA.

T-tube care
Secure the tube by taping it to body Attached to a bile bag for a week or possibly longer Keep the tube and bag below surgical wound Secure connections between tube and drainage bag Avoid kinks in the tubing Monitor drainage nature colour, consistency and amount Observe insertion site daily for leakage, redness, tenderness or swelling. Change dressing if it is moist.

T-tube

Post-op Complications
Monitor for complications involving obstructed bile drainage such as: Post-cholecystectomy syndrome-fever Excessive abdominal pain Jaundice

Dressing
Check incision for signs of infection: elevate temperature, increased swelling, redness or smelly wound drainage (little swelling & bruising is normal) Clean and dry daily during the healing period to help to prevent a wound infection Used aseptic technique

Healing wound after removal of stitches/ staplers

Sterile-strips may be present on your incisions. These will fall off in about 1-2 weeks. Do not pull off earlier. If your dressing becomes soiled, or loosens and comes off prior to 48 hours after surgery, you may replace it with a dry sterile dressing and tape.

Laboratory Results (Post-operation)


Urea Creatinine Sodium Potassium Chloride Glucose WBC Hb Platelet count PT APTT 7.2 mmol/L (3.6-7.2 mmol/L) 70 mol/L (62-124 mol/L) 138 mmol/L (135-145 mmol/L) 3.0 mmol/L (3.5-5.0 mmol/L) 98 mmol/L (97-107 mmol/L) 4.2 mmol/L (3.3-6.05 mmol/L) 12.4 x 10/uL (4.5-11 x 10/uL) 11.0 g/dL (13-18 g/dL) 277 x 10/uL (150-450 x 10/uL) 10.2 secs (9.5-12 secs) 31.9 secs (30-40 secs)

Follow up care
Potassium (3.0 mmol/L)- may indicate fluid/ electrolyte imbalance Serve anti-emetics Never give bolus!!!! KCL replacement by: - IV KCL premixed - e.g. IV KCL 10mmol in N/S100ml Oral replacement if tolerated - e.g. Span K Monitor serum potassium

WBC ( 12.4 x 10/uL)- may indicate infection Serve antibiotics as ordered Daily FBC, serum bilirubin Monitor signs of infection - pain, fever, redness, swelling Monitor for signs of obstruction

Hb (11.0 g/dL) may indicate haemorrhage Monitor bleeding at incision site, amount of drainage Daily FBC, Group & Cross match Administer blood transfusion as ordered

Discharge teaching plan

Discharge criteria
Temperature < 37.6C (Consecutive 2 days) Pain score <3 on oral analgesics Stable medical conditions (Vital signs, lab test) T-tube drainage <1L per day Wound is clean and dry Patient/family understand wound care Patient/family demonstrate correct T-tube care

Diet
Maintain a low-fat, high carbohydrate & high protein diet. Eat frequent, small meals. Avoid carbonated beverages for 3 to 4 weeks.

Low-fat diet

Dairy products

Greasy food

Activity
Begin light exercise (walking) Avoid heavy lifting for 4-6 weeks

Wound care
Observe for signs of infection- elevated temperature, redness, swelling, odour & discharges Keep incision area clean and dry Care of T-tube (Dressing & drainage) Use aseptic technique

Medications & follow-up


Compliance to medications Educate on side effects Stress importance of follow-up visits. Provide all information. Example: Appointment to polyclinic for wound/ T-tube inspection.

When to see doctor?


Persistent fever above 38C Nausea or vomiting Persistent, increasing pain Bleeding Increased redness, tenderness or swelling at incision site Change in skin colour/jaundice

Conclusion
Open cholecystectomy is a major surgical procedure involving the removal of the gallbladder through an incision in the abdomen. Open surgery involves more pain afterward and a longer recovery period than laparoscopic surgery. After gallbladder surgery, some people have on going abdominal symptoms, such as pain, bloating, gas, or diarrhoea (post-cholecystectomy syndrome). Patients need to watch their diet by consuming healthy intake & alert for any complications. Most people can return to their normal activities in 4 to 6 weeks.

References

Asad, F. (2010, August 13). Cholecystectomy Open and laparoscopic [Video file]. Retrieved from http://www.youtube.com/watch? v=N56Z7OLlIOw Baltimore, J. J., & Davidson, J. (2007). Caring for a patient with acute cholecystitis. Nursing2007, 37(3), 64hn1-64hn4 Berman, A., Kozier, B., Erb, G., & Synder, S. (2008). Kozier and Erbs fundamentals of nursing: Concepts, process and practice (8th ed.). New Jersey: Prentice Hall Health. Canobbio, M. M. (2006). Mosbys handbook of patient teaching (3rd ed.). St Louis: Mosby Inc. Drugs.com. (2012, November 7). Open cholecystectomy: Inpatient care [Web log post]. Retrieved from http:www.drugs.com/cg/ open-cholecystectomy-inpatient-care.html

Health Promotion Board. (2012, September 27). BMI ranges. Retrieved from http://www.hbp.gov.sg/HOPPortal/healtharticle/HBP-03940 LeMone, P., & Burke, K. M. (2008). Medical-surgical nursing: Critical thinking in client care (4th ed.). New York: Addison Wesley Publishing. Lubin, M. F., Smith III, R. B., Dodson, T. F., Spell, N. O., & Walker, H. K. (2010). Medical management of the surgical patient: A textbook of perioperative medicine (4th ed.). United Kingdom: Cambridge University Press. Mayo Clinic Staff. (2010, December 28). Cholecystectomy how you prepare [Web log post]. Retrieved from http://www.mayoclinic.com/health/cholecystectomy/MY00372/D SECTION= how-you-prepare

Mayo Clinic Staff. (2011, September 1). Cholecystitis [Web log post]. Retrieved from http://www.mayoclinic.com/health/cholecystitis/ DS01153 Perry, A. G., & Potter, P. A. (2009). Fundamentals of nursing (7th ed.). St Louis: Mosby Inc. Pudner, R. (2010). Nursing the surgical patient (3rd ed.). United Kingdom: Elsevier Limited. Rogers, A. (2011, August 17). Gallbladder removal open [Web log post]. Retrieved from http://www.nlm.nih.gov/medlineplus/ency/ article/002930/htm Rothrock, J. C., & Alexander, S. M. (2012). Alexanders surgical procedures. St Louis: Mosby Inc. Rothrock, J. C., & McEwen, D. R. (2011). Care of the patient in surgery (14th ed.). St Louis: Mosby Inc.

Smeltzer, S. C., Bare, B. G., Hinkle, J. L., & Cheever, K. H. (2010). Brunner & Suddarths textbook of medical-surgical nursing (12th ed.). Philadelphia: Wolters Kluwer Health. Strasberg, S. M. (2008).Clinical practice: Acute calculous . New England Journal of Medicine, 358(26), 2804-2811. Vorvick, L. J. (2012, November 14). Acute cholecystitis. Times Health Guide. Retrieved from http://health.nytimes.com/health/guides/ disease/acute-cholecystitis-gallstones/diagnosis.htm WebMD. (2009, July 22). Cholecystitis-overview [Web log post]. Retrieved from http://www.webmd.com/digestive-disorders/tc/ cholecystitis-overview