Definition
Cholelithiasis
- Refers
to formation of calculi (e.g. gallstones) in the gallbladder.
Cholecystitis
- Is
acute or chronic inflammation of the gallbladder.
- Acute cholecystits – may be
calculous (with gallstones) or acalculous (with gallstones).
- Chronic cholecystitis – may
follow acute cholecystitis, although it often occurs independently. It is
usually associated with gallstone formation.
Risk Factors
Cholelithiasis
Results from changes in bile components or bile
stasis, associated with:
- Infection
- Cirrhosis
- Pancreatitis
- Celiac
disease
- Diabetes
mellitus
- Pregnancy
- Hormonal
contraceptive use
Cholecystitis
- Obstruction
of the cystic duct by an impacted gallstone
- Tissue
damage due to trauma, massive burns, or surgery
- Gram-negative
septicemia
- Multiple
blood transfusion
- Prolonged
fasting
- Hypertension
- Overuse
of opioid analgesics
Pathophysiology
Cholelithiasis
Calculi usually from solid constituents of bile; the three major
types are:
- Cholesterol gallstones – the most
common type, thought to form in supersaturated bile
- Pigment gallstones – formed
mainly of unconjugated pigments in bile precipitate
- Mixed types – with
characteristics of pigment and cholesterol stones.
Gallstones can obstruct the cystic duct, causing cholecystitsi,
or the common bile duct, which is called choledocholithiasis.
Cholecystitis
- In
acute and chronic cholecystitis, inflammation causes the gallbladder wall
to become thickened and edematous and causes the cystic lumen to increase
in diameter.
- If
inflammation spreads to the common bile duct, obstruction of bile drainage
can lead to jaundice. Other possible complications include: (Empyema i.e.
pus-filled gallbladder, perforation, emphysematous cholecystitis)
Assessment/Clinical Manifestations/Signs And Symptoms
Cholelithiasis (up to ½ of persons with gallstones are
asymptomatic; however possible clinical manifestations include the following)
- Episodic
(commonly after a high-fat meal), cramping pain in the right upper
abdominal quadrant or the epigastrium, possibly radiating to the back near
the right scapular tip (i.e. biliary colic)
- Nausea
and vomiting
- Fat
intolerance
- Fever
and leukocystosis
- Signs
and symptoms of jaundice
Acute Cholecystitis
- Biliary
colic
- Tenderness
and rigidity in the right upper quadrant elicited on palpation (i.e.
Murphy’s sign)
- Fever
- Nausea
and vomiting
- Fat
intolerance
- Signs
and symptoms of jaundice
Chronic Cholecystitis
- Pain,
which is less severe than in the acute form
- Fever,
which is less severe than in the acute form
- Fat
intolerance
- Heartburn
- Flatulence
Laboratory and diagnostic study findings
Cholelithiasis
- Biliary
ultrasonography (i.e. cholecystosonography) can detect gallstones in most
cases.
Cholecystitis
- White
blood cell count reveals leukocytosis
- Serum
alkaline phosphatase is elevated
- Ultrasonography
detects gallstone
- Endoscopic
retrograde cholangiopancreatography may reveal inflamed common bile ducts,
gallbladder, and gallstones.
- Percutaneous
transheptic cholangiography can identify gallstones within the bile ducts.
Medical Management
Teach the client about planned treatments.
- Chenodeoxycholic
acid is administered to dissolve gallstones. It is effective in dissolving
about 60% of radiolucent gallstones. Pigment gallstones cannot be
dissolves and must be excised.
- Nonsurgical
removal, such as lithotripsy or extracorpeal shock wave therapy, may be
implemented.
Surgical treatment may be ordered.
Laparoscopic cholecytectomy (usually outpatient surgery) is
performed through a small incision made through the abdominal wall in the
umbilicus.
- Assess
incision sites for infection. Instruct the client to notify the health
care provider if loss of appetite, vomiting, pain, abdominal distention,
or fever occur.
- Advise
the client that he will need assistance at home for 2 to 3 days.
Cholecystectomy is removal of the gallbladder after ligation of
the cystic duct and artery. Inform the client that a T-tube will be inserted to
drain blood; serosanguineous fluids, and bile and that the T-tube must be taped
below the incision
Choledochostomy is an incision into the common bile duct for
calculi removal.
Cholecystomy is the surgical opening of the gallbladder for
removal of stones, bile, or pus, after which a drainage tube is placed.
Nursing Diagnosis
- Acute
pain secondary to biliary obstruction
- Ineffective
coping related to nausea
- Deficient
knowledge related to diagnosis
- Impaired
gas exchange related to high abdominal surgical incision.
- Impaired
skin integrity related to altered biliary drainage after surgical
incision.
- Imbalanced
nutrition related to inadequate bile secretion.
Nursing Management
Provide nursing interventions during an acute gallbladder
attack.
- Intervene
to relive pain; give prescribed analgesics
- Promote
adequate rest
- Administer
IV fluids, monitor intake and output
- Monitor
nasogastric tube and suctioning
- Administer
antibiotics if prescribed.
Provide adequate nutrition.
- Assess
nutritional status. Encourage a high-protein, high-carbohydrate, low-fat
diet.
Nursing Care Plan
1. Nursing
Diagnosis
- Fluid
Volume, risk for deficient
Risk factors may include
- Excessive
losses through gastric suction; vomiting, distension, and gastric hypermotility
- Medically
restricted intake
- Altered
clotting process
Possibly evidenced by
- Not applicable. A risk diagnosis
is not evidenced by signs and symptoms, as the problem has not occurred
and nursing interventions are directed at prevention.
Desired Outcomes
- Demonstrate
adequate fluid balance evidenced by stable vital signs, moist mucous
membranes, good skin turgor, capillary refill, individually appropriate
urinary output, absence of vomiting.
Nursing Interventions
- Maintain
accurate record of I&O, noting output less than intake, increased
urine specific gravity. Assess skin and mucous membranes, peripheral
pulses, and capillary refill.
- Rationale: To
provide information about fluid status and circulating volume needing
replacement.
- Monitor
for signs and symptoms of increased or continued nausea or vomiting,
abdominal cramps, weakness, twitching, seizures, irregular heart rate,
paresthesia, hypoactive or absent bowel sounds, depressed respirations.
- Rationale: Prolonged
vomiting, gastric aspiration, and restricted oral intake can lead to
deficits in sodium, potassium, and chloride.
·
Eliminate noxious sights or smells from environment.
·
Rationale: Reduces stimulation of vomiting center.
·
Perform frequent oral hygiene with alcohol-free mouthwash; apply
lubricants.
·
Rationale: Decreases dryness of oral mucous membranes;
reduces risk of oral bleeding.
·
Use small-gauge needles for injections and apply firm pressure
for longer than usual after venipuncture.
·
Rationale: Reduces trauma, risk of bleeding or hematoma
formation.
·
Assess for unusual bleeding: oozing from injection sites,
epistaxis, bleeding gums, ecchymosis, petechiae, hematemesis or melena.
·
Rationale: Prothrombin is reduced and coagulation time
prolonged when bile flow is obstructed, increasing risk of bleeding or
hemorrhage.
·
Keep patient NPO as necessary.
·
Rationale: Decreases GI secretions and motility.
·
Insert NG tube, connect to suction, and maintain patency as
indicated.
- Rationale: To
rest the GI Tract
2. Nursing
Diagnosis
May be related to
- Biological
injuring agents: obstruction/ductal spasm, inflammatory process, tissue
ischemia/necrosis
Possibly evidenced by
- Reports
of pain, biliary colic (waves of pain)
- Facial
mask of pain; guarding behavior
- Autonomic
responses (changes in BP, pulse)
- Self-focusing;
narrowed focus
Desired Outcomes
- Report
pain is relieved/controlled.
- Demonstrate
use of relaxation skills and diversional activities as indicated for
individual situation.
Nursing Interventions
·
Observe and document location, severity (0–10 scale), and
character of pain (steady, intermittent, colicky).
·
Rationale: Assists in differentiating cause of pain, and
provides information about disease progression and resolution, development of
complications, and effectiveness of interventions.
·
Note response to medication, and report to physician if pain is
not being relieved.
·
Rationale: Severe pain not relieved by routine measures may
indicate developing complications or need for further intervention.
·
Promote bedrest, allowing patient to assume position of comfort.
·
Rationale: Bedrest in low-Fowler’s position reduces
intra-abdominal pressure; however, patient will naturally assume least painful
position.
·
Use soft or cotton linens; calamine lotion, oil bath; cool or
moist compresses as indicated.
·
Rationale: Reduces irritation and dryness of the skin and
itching sensation.
·
Control environmental temperature.
·
Rationale: Cool surroundings aid in minimizing dermal
discomfort.
·
Encourage use of relaxation techniques. Provide diversional
activities.
·
Rationale: Promotes rest, redirects attention, may enhance
coping.
·
Make time to listen to and maintain frequent contact with
patient.
·
Rationale: Helpful in alleviating anxiety and refocusing
attention, which can relieve pain.
·
Maintain NPO status, insert and/or maintain NG suction as
indicated.
·
Rationale: Removes gastric secretions that stimulate
release of cholecystokinin and gallbladder contractions.
·
Administer medications as
indicated:
·
Anticholinergics: atropine, propantheline (Pro-Banthı-ne);
·
Rationale: Relieves reflex spasm and smooth muscle
contraction and assists with pain management.
·
Sedatives: phenobarbital;
·
Rationale: Promotes rest and relaxes smooth muscle,
relieving pain.
·
Narcotics: meperidine hydrochloride (Demerol), morphine
sulfate;
·
Rationale: Given to reduce severe pain. Morphine is
used with caution because it may increase spasms of the sphincter of Oddi,
although nitroglycerin may be given to reduce morphine-induced spasms
if they occur.
·
Monoctanoin (Moctanin);
·
Rationale: This medication may be used after a
cholecystectomy for retained stones or for newly formed large stones in the
bile duct. It is a lengthy treatment (1–3 wk) and is administered via a
nasal-biliary tube. A cholangiogram is done periodically to monitor stone
dissolution.
·
Smooth muscle relaxants: papaverine (Pavabid), nitroglycerin,
amyl nitrite;
·
Rationale: Relieves ductal spasm.
·
Chenodeoxycholic acid (Chenix), ursodeoxycholic acid (Urso,
Actigall);
·
Rationale: These natural bile acids decrease cholesterol
synthesis, dissolving gallstones. Success of this treatment depends on the
number and size of gallstones (preferably three or fewer stones smaller than 20
min in diameter) floating in a functioning gallbladder.
·
Antibiotics.
·
Rationale: To treat infectious process, reducing
inflammation.
3. Nursing Diagnosis
- Nutrition:
Less Than Body Requirements, Risk for Imbalanced
Risk factors may include
- Self-imposed
or prescribed dietary restrictions, nausea/vomiting, dyspepsia, pain
- Loss
of nutrients; impaired fat digestion due to obstruction of bile flow
Possibly evidenced by
- Not applicable. A risk diagnosis
is not evidenced by signs and symptoms, as the problem has not occurred
and nursing interventions are directed at prevention.
Desired Outcomes
- Report
relief of nausea/vomiting.
- Demonstrate
progression toward desired weight gain or maintain weight as individually
appropriate.
Nursing Interventions
·
Calculate caloric intake. Keep comments about appetite to a
minimum.
·
Rationale: Identifies nutritional deficiencies and/or
needs. Focusing on problem creates a negative atmosphere and may interfere with
intake.
·
Weigh as indicated.
·
Rationale: Monitors effectiveness of dietary plan.
·
Consult with patient about likes and dislikes, foods that cause
distress, and preferred meal schedule.
·
Rationale: Involving patient in planning enables patient to
have a sense of control and encourages eating.
·
Provide a pleasant atmosphere at mealtime; remove noxious
stimuli.
·
Rationale: Useful in promoting appetite/reducing nausea.
·
Provide oral hygiene before meals.
·
Rationale: A clean mouth enhances appetite.
·
Offer effervescent drinks with meals, if tolerated.
·
Rationale: May lessen nausea and relieve gas. Note:May
be contraindicated if beverage causes gas formation/gastric discomfort.
·
Assess for abdominal distension, frequent belching, guarding,
reluctance to move.
·
Rationale: Nonverbal signs of discomfort associated with
impaired digestion, gas pain.
·
Ambulate and increase activity as tolerated.
·
Rationale: Helpful in expulsion of flatus, reduction of
abdominal distension. Contributes to overall recovery and sense of well-being
and decreases possibility of secondary problems related to immobility
(pneumonia, thrombophlebitis).
·
Consult with dietitian or nutritional support team as indicated.
·
Rationale: Useful in establishing individual nutritional
needs and most appropriate route.
·
Begin low-fat liquid diet after NG tube is removed.
·
Rationale: Limiting fat content reduces stimulation of
gallbladder and pain associated with incomplete fat digestion and is helpful in
preventing recurrence.
·
Advance diet as tolerated, usually low-fat, high-fiber. Restrict
gas-producing foods (onions, cabbage, popcorn) and foods or fluids high in fats
(butter, fried foods, nuts).
·
Rationale: Meets nutritional requirements while minimizing
stimulation of the gallbladder.
·
Administer bile salts: Bilron, Zanchol, dehydrocholic acid
(Decholin), as indicated.
·
Rationale: Promotes digestion and absorption of fats,
fat-soluble vitamins, cholesterol. Useful in chronic cholecystitis.
·
Monitor laboratory studies: BUN, prealbumin, albumin, total
protein, transferrin levels.
·
Rationale: Provides information about nutritional deficits
or effectiveness of therapy.
·
Provide parenteral and/or enteral feedings as needed.
·
Rationale: Alternative feeding may be required depending on
degree of disability and gallbladder involvement and need for prolonged gastric
rest.
4. Nursing
Diagnosis
May be related to
- Lack
of knowledge/recall
- Information
misinterpretation
- Unfamiliarity
with information resources
Possibly evidenced by
- Questions;
request for information
- Statement
of misconception
- Inaccurate
follow-through of instruction
- Development
of preventable complications
Desired Outcomes
- Verbalize
understanding of disease process, prognosis, potential complications.
- Verbalize
understanding of therapeutic needs.
- Initiate
necessary lifestyle changes and participate in treatment regimen.
Nursing Interventions
·
Explain reasons for test procedures and preparations as needed.
·
Rationale: Information can decrease anxiety, thereby
reducing sympathetic stimulation.
·
Review disease process and prognosis. Discuss hospitalization
and prospective treatment as indicated. Encourage questions, expression of
concern.
·
Rationale: Provides knowledge base from which patient can
make informed choices. Effective communication and support at this time can
diminish anxiety and promote healing.
·
Review drug regimen, possible side effects.
·
Rationale: Gallstones often recur, necessitating long-term
therapy. Development of diarrhea or cramps during chenodiol therapy may be
dose-related or correctable. Note: Women of childbearing age should
be counseled regarding birth control to prevent pregnancy and risk of fetal
hepatic damage.
·
Discuss weight reduction programs if indicated
·
Rationale: Obesity is a risk factor associated with
cholecystitis, and weight loss is beneficial in medical management of chronic
condition.
·
Instruct patient to avoid food/fluids high in fats (pork,
gravies, nuts, fried foods, butter, whole milk, ice cream), gas producers
(cabbage, beans, onions, carbonated beverages), or gastric irritants ( spicy
foods, caffeine, citrus).
·
Rationale: Limits or prevents recurrence of
gallbladder attacks.
·
Review signs and symptoms requiring medical intervention:
recurrent fever; persistent nausea and vomiting, or pain; jaundice of skin or
eyes, itching; dark urine; clay-colored stools; blood in urine, stools,
vomitus; or bleeding from mucous membranes.
·
Rationale: Indicative of progression of disease process and
development of complications requiring further intervention.
·
Recommend resting in semi-Fowler’s position after meals.
·
Rationale: Promotes flow of bile and general relaxation
during initial digestive process.
·
Suggest patient limit gum chewing, sucking on straw and hard
candy, or smoking.
·
Rationale: Promotes gas formation, which can increase
gastric distension and discomfort.
·
Discuss avoidance of aspirin-containing products, forceful
blowing of nose, straining for bowel movement, contact sports.
·
Rationale: Reduces risk of bleeding related to changes in
coagulation time, mucosal irritation, and trauma.
·
Recommend use of soft toothbrush, electric razor.
·
Rationale: Reduces risk of bleeding related to changes in
coagulation time, mucosal irritation, and trauma.