1. Choleycystitis

2. 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.

3. Key points
Calculi 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.

4. 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.
Cholecystitis (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

5. 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) Fs
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)

6. 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.

7. Triggering Factors Trauma Surgery Coronary events Diabetes Fasting
Immobility
Hormone replacement therapy (HRT)
Pregnancy

8. 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)

9. 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.

10. 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.

11. 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]).

12. 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.

13. 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)

14. NANDA Nursing Diagnoses
Acute pain
Impaired gas exchange
Risk for infection
Impaired skin integrity
Imbalanced nutrition, less than body requirements,
Deficient knowledge

15. 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

16. 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.

17. 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.

18. 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.

19. 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.