4 Cholecystitis and Cholelithiasis

4 Cholecystitis and Cholelithiasis Cholecystitis is the inflammation of the gallbladder, usually associated with gallstones impacted in the cystic duct. Stones (calculi) are made up of cholesterol, calcium bilirubinate, or a mixture caused by changes in the bile composition. Gallstones can develop in the common bile duct, the cystic duct, hepatic duct, small bile duct, and pancreatic duct. Crystals can also form in the submucosa of the gallbladder causing widespread inflammation. Acute cholecystitis with cholelithiasis is usually treated by surgery, although several other treatment methods (fragmentation and dissolution of stones) are now being used. Choleslithiasis, stones or calculi in the gallbladder, results from changes in bile components. Gallstones are made of cholesterol, calcium bilirubinate, or a mix of cholesterol and bilirubin. They arise during periods of sluggishness in the gallbladder due to pregnancy, hormonal contraceptives, diabetes mellitus, celiac disease, cirrhosis of the liver, and pancreatitis. Nursing Care Plans Nursing care planning and management for patients with cholecystitis include relieving pain and promoting rest, maintaining fluid and electrolyte balance, preventing complications, and provision of information about disease process, prognosis, and treatment. Here are four (4) nursing care plans and nursing diagnosis for cholecystitis (cholelithiasis): Risk for Deficient Fluid Volume Acute Pain Risk for Imbalanced Nutrition: Less Than Body Requirements Deficient Knowledge Risk for Deficient Fluid Volume Nursing Diagnosis Risk for Deficient Fluid Volume 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 Rationale Maintain accurate record of I&O, noting output less than intake, increased3urine3specific gravity. Assess skin and mucous membranes, peripheral pulses, and capillary refill. To provide information about fluid status and circulating volume needing replacement. Monitor for signs and symptoms of increased or continued3nausea3or vomiting, abdominal cramps, weakness, twitching, seizures, irregular heart rate, paresthesia, hypoactive or absent bowel sounds, depressed respirations. Prolonged vomiting, gastric3aspiration, and restricted oral intake can lead to deficits in3sodium,3potassium, and chloride. Eliminate noxious sights or smells Reduces stimulation of Nursing Interventions Rationale from environment. vomiting center. Perform frequent oral hygiene with alcohol-free mouthwash; apply lubricants. Decreases dryness of oral mucous membranes; reduces risk of oral3bleeding. Use small-gauge needles for injections and apply firm pressure for longer than usual after venipuncture. Reduces trauma, risk of bleeding or hematoma formation. Assess for unusual bleeding: oozing from injection sites, epistaxis, bleeding gums, ecchymosis, petechiae, hematemesis or melena. Prothrombin is reduced and coagulation time prolonged when bile flow is obstructed, increasing risk of bleeding or hemorrhage. Keep patient NPO as necessary. Decreases GI secretions and motility. Insert3NG tube, connect to suction, and maintain patency as indicated. To rest the GI Tract Acute Pain Nursing Diagnosis Acute Pain 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 Rationale Observe and document location, severity (0–10 scale), and character of pain (steady, intermittent, colicky). 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. 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. 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 Reduces irritation and dryness of Nursing Interventions Rationale or moist compresses as indicated. the skin and itching sensation. Control environmental temperature. Cool surroundings aid in minimizing dermal discomfort. Encourage use of relaxation techniques. Provide diversional activities. Promotes rest, redirects attention, may enhance coping. Make time to listen to and maintain frequent contact with patient. Helpful in alleviating3anxiety3and refocusing attention, which can relieve pain. Maintain NPO status, insert and/or maintain NG suction as indicated. Removes gastric secretions that stimulate release of cholecystokinin and gallbladder contractions. Administer medications as indicated:  Anticholinergics: atropine, propantheline (Pro-Banthı-ne) Relieves reflex spasm and smooth3muscle3contraction and assists with pain management.  Sedatives:3phenobarbital Promotes rest and relaxes smooth muscle, relieving pain.  Narcotics:3meperidine hydrochloride (Demerol), morphine sulfate Given to reduce severe pain.3Morphine is used with caution because it may increase spasms of the sphincter of Oddi, although3nitroglycerin3may be given to reduce morphine-induced Nursing Interventions Rationale spasms if they occur.  Monoctanoin (Moctanin) 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 Relieves ductal spasm.  Chenodeoxycholic acid (Chenix), ursodeoxycholic acid (Urso, Actigall) 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 To treat infectious process, reducing inflammation. Risk for Imbalanced Nutrition: Less Than Body Requirements Nursing Diagnosis Risk for Imbalanced Nutrition: Less Than Body Requirements 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 Rationale Calculate caloric intake. Keep comments about appetite to a minimum. Identifies nutritional deficiencies and/or needs. Focusing on problem creates a negative atmosphere and may interfere with intake. Weigh as indicated. Monitors effectiveness of dietary plan. Consult with patient about likes and dislikes, foods that cause distress, and preferred meal schedule. Involving patient in planning enables patient to have a sense of control and encourages eating. Provide a pleasant atmosphere at mealtime; remove noxious stimuli. Useful in promoting appetite/reducing nausea. Provide oral hygiene before meals. A clean3mouth3enhances appetite. Nursing Interventions Rationale May lessen nausea and relieve Offer effervescent drinks gas.3Note:May be contraindicated if with meals, if tolerated. beverage causes gas formation/gastric discomfort. Assess for abdominal distension, frequent belching, guarding, reluctance to move. Nonverbal signs of discomfort associated with impaired digestion, gas pain. Ambulate and increase activity as tolerated. 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,3thrombophlebitis). Consult with dietitian or nutritional support team as indicated. Useful in establishing individual nutritional needs and most appropriate route. Begin low-fat liquid diet after NG tube is removed. 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 lowfat, high-fiber. Restrict gas-producing foods (onions, cabbage, popcorn) and foods or fluids high in fats Meets nutritional requirements while minimizing stimulation of the gallbladder. Nursing Interventions Rationale (butter, fried foods, nuts). Administer bile salts:3Bilron, Zanchol, dehydrocholic acid (Decholin), as indicated. Promotes digestion and absorption of fats, fat-soluble vitamins, cholesterol. Useful in chronic cholecystitis. Monitor laboratory studies:3BUN, prealbumin, albumin, total protein, transferrin levels. Provides information about nutritional deficits or effectiveness of therapy. Provide parenteral and/or enteral feedings as needed. Alternative feeding may be required depending on degree of disability and gallbladder involvement and need for prolonged gastric rest. Deficient Knowledge Nursing Diagnosis Deficient Knowledge 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 Rationale Explain reasons for test procedures and preparations as needed. 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. 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. Gallstones often recur, necessitating long-term therapy. Development of3diarrhea3or cramps during chenodiol therapy may be dose-related or correctable.3Note:3Women of childbearing age should be counseled regarding birth control to prevent pregnancy and risk of fetal hepatic damage. Nursing Interventions 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 Limits or prevents3recurrence of cream), gas producers gallbladder attacks. (cabbage, beans, onions, carbonated beverages), or gastric irritants ( spicy foods, caffeine, citrus). Review signs and symptoms requiring medical intervention: recurrent3fever; persistent nausea and vomiting, or pain; jaundice of skin or eyes, itching; dark urine; clay-colored stools;3blood3in urine, stools, vomitus; or bleeding from mucous membranes. Indicative of progression of disease process and development of complications requiring further intervention. Recommend resting in semi- Promotes flow of bile and general Fowler’s position after relaxation during initial digestive meals. process. Nursing Interventions Rationale Suggest patient limit gum chewing, sucking on straw and hard candy, or smoking. Promotes gas formation, which can increase gastric distension and discomfort. Discuss avoidance of3aspirin-containing products, forceful blowing of nose, straining for bowel movement, contact sports. Reduces risk of bleeding related to changes in coagulation time, mucosal irritation, and trauma. Recommend use of soft toothbrush, electric razor. Reduces risk of bleeding related to changes in coagulation time, mucosal irritation, and trauma.