Chapter 50 - Medical-Surgical Nursing PDF

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Inflammation (Chapter 50) Gallbladder PowerPoint Notes:  Inflammation: A nonspecific complex response to reduce effects of what the body sees as harmful -> caused by injury, infection, auto immunity, toxins and irritants  An alternation in bile that flows through the hepatic, cystic common bile duct (CBD) is a common problem  Cholelithiasis is the formation of stones in the gallbladder or biliary duct system  Gallbladder small and hollow organ, pear shaped, can hold 50 mL of volume, and stores and concentrates bile

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Gallstones most form in the gallbladder and migrate into the ducts known as cholangitis o Early manifestations may be vague Obstruction of the ducts may cause biliary colic o Severe and steady pain in epigatric regions (RUQ) o May radiate to back, right scapula, or shoulder Cholecystitis is inflammation of the gallbladder o Acute: after stones obstruct the cystic duct -> beings with attack of biliary colic, pain last longer than colic causing anorexia, nausea, and vomiting o Chronic: can be caused by repeated bouts of acute cholecystitis -> persistent irritation of gallbladder wall by stones o Complications: empyema, gangrene, perforations (peritonitis or abscess formation), formation of fistula into adjacent organ, gallstone ileus o Factors that contribute: abnormal bile composition, biliary stasis, inflammation of gallbladder o 80% consist of cholesterol -> bile is supersaturated with cholesterol it precipitates out to form stones o Risk factors: age, family history, race (native Americans, Hispanics), obesity, rapid weight loss, being female, biliary stasis, certain diseases Choleslithiasis: manifestations: pain -> abrupt onset, severe, steady, RUQ, last30 minutes to an hour, nausea, vomiting Cholecystitis: manifestations: pain -> severe, steady, abrupt, last 12-18 hours, generalized in RUQ may radiate to back, right scapula, shoulder, aggravated by movement and breathing, nausea, anorexia, vomiting, RUQ tenderness, guarding, chills and fever Surgery is indicated when there is a frequency of symptoms or acute choleystitis or very large stones Diagnostic test: serum bilirubin, CBC, serum amylase, lipase, abdominal xray, ultrasounds of gallbladder, oral cholecystogram, cholescintigraphy, gallbladder scan Surgeries:

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o Laparoscopic Cholecystectomy: surgery of choice o Cholecystectomy with CBD exploration: when stones lodged in ducts o Cholecystectomy to drain gallbladder o Choledochostomy remove stones position a T-tube in CBD Non-surgical Treatment: o Shock wave lithotripsy: to dissolve large gallstones used with drug therapy o Percutaneous cholecystostomy: ultrasound guided drainage of gallbladder, used for high risk patients Pharmacologic Therapy: for patients who refuse or cannot have surgery o Ursodiol and chenodiol are used to dissolve gallstones  Best for stones with high cholesterol content  Costly and may take up to 2 years with high reoccurrence probability o Antibiotics for infection o Narcotics for pain relief Non-Pharmacologic Therapy: o During acute attack: NPO, NG tube to relieve nausea and vomiting o Dietary fat intake may be limited o If bile is obstructed administer fat soluble vitamins and bile salts Life Span Considerations: o Children and adolescents have increased admission and may not present with classic symptoms o Patients with sickle cell disease and bile abnormality often require cholecystectomy and may experience complications o Pregnant women: most common reason for postpartum hospitalization o Elderly patients may only present with localized tenderness Nursing Process: o Assessment:  Duration of symptoms  Risk factors  Chronic diseases  Diet  Oral contraceptives or possibility of being pregnant  Abdominal tenderness, color of skin, color of urine and stool o Diagnosis:  Risk for Infection  Acute Pain  Imbalances Nutrition: less than the body requires o Outcomes:  No S/S of infection  Report pain control  Understand low fat diet and adequate intake of fat soluble vitamins  Verbalize awareness of S/S and when to call doctor o Implementation:  Caring for postoperative patients: monitor vital q4h, assist with coughing and deep breathing, use of incentive spirometer, place is fowlers position, administer antibiotics as ordered  Care of T-tube: ensure proper connection to sterile container, monitor drainage and record output, place in fowlers position, assess skin of bile leakage, teach patient care of T-tube  Provide effective pain management: discuss relationship between fat intake and pain, teach ways to reduce fat intake, withhold oral foods, insert NG tube if ordered, administer analgesia, place in fowlers position

Promote balanced nutrition: diet history, height, weight, skinfold measurements, evaluate laboratory results, administer vitamin supplements as ordered o Evaluation  Low fat diet high in fat soluble vitamins, good pain control, temp within normal range, no S/S of infection, Abdominal assessment: o Pain? -> if so, rate it, place it, describe it. o Bowel habits? o Change in appetite? Food Intolerances? o Normal diet? What have they eaten in the past 24 hours? o History of problems? o Urinary and menstruation? o Want them supine with pillow under head and knees o Expose abdomen o Look -> Hearing -> Feel o Is there abdomen distended and what girth o Abdominal movement? Sometimes you can see the movement o Listen in all 4Q listen for vascular sounds -> should not be able to hear them o Resonant (hollow) -> should be o Dull (solid) o First touch lightly, ask if its tender or if they are guarding o Then go deeper and try to feel for the liver and spleen Bristol Stool Chart -> 1 – 7 o 1 being constipated hard to pass o 7 being almost entirely liquid o Is there blood or mucus in the stool o Blood? o Hx with problems? 

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Gallbladder is connected to the common bile duct by the cystic duct If the flow of bile is impeded bilirubin does enter the intestine, causing an increase in blood levels Disorders of the gallbladder in include cholecystitis and cholelithiasis Cholecystitis is inflammation of the gallbladder being either chronic or acute o Causes pain and tenderness in the URQ that may radiate to midsternal area or right shoulder o Associated with nausea, vomiting, and signs of acute inflammation o An empyema of the gallbladder develops if gallbladder becomes filled with purulent fluid (pus)  In calculus cholecystitis a gallbladder stone obstructs the outflow of bile (cause of 90% of cases of acute cholecystitis). Gangrene of the gallbladder and perforation may result from the build up bile causing edema and vascular supply is compromised. Secondary bacterial infection of the bile is common in 50% of cases.  Acalculus cholecystitis is acute bladder inflammation in the absence of obstruction by gallstones. Occurs after major surgical procedures, severe trauma, or burns. Other factors associated are torsion, cystic duct obstruction, primary bacterial infections of the gallbladder, and multiple blood

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transfusions. Caused by electrolyte and fluid alternations, bile stasis, and increased viscosity of bile. Cholelithiasis or gallstones, form in gallbladder from solid constituents of bile o Uncommon in children and young adults -> more prevalent with increasing age o Affects 70% of women by the age of 70

Pathophysiology  Gallstones are either composed of pigment or cholesterol  Pigments: o 10-25% of cases are caused by pigment: pigments in bile form stones o Increased risk with cirrhosis, hemolysis, and infections of biliary tract o They must be removed surgically  Cholesterol: o 75% of cases o Cholesterol solubility depends on bile acids and lecithin in bile o In gallstone-prone patients there is decreased bile acid synthesis and increased cholesterol synthesis in the liver -> bile is super saturated with cholesterol -> forming stones o The saturated bile predisposes the formation of gallstones and acts as an irritants that produces inflammation of the gallbladder mucosa o Affects more women than men, especially older than 40 y.o. -> more frequent in those who use oral contraceptives -> increases biliary cholesterol saturation o The occurrence increases with age because of hepatic excretion of cholesterol ad decreased acid bile synthesis o Greater chance for people with diabetes or GI diseases Clinical Manifestations  Gallstones can produce no pain and mild GI symptoms  Epigastric distress such as fullness, abdominal distention, and vague pain in RUQ may occur  Distress may follow after meals in fried or fatty foods  Pain and Biliary Colic (sudden pain): o When gallstones obstruct the biliary duct the gallbladder becomes distended, inflamed and infected -> acute cholecystitis  The patient will have a fever and palpable abd mass, RUQ pain that radiates to the back or right shoulder  Biliary colic is associated with N/V  In some the pain is constant or colicky  The enlargement of the gallbladder will cause pain in RUQ during deep inspiration and prevent full inspiration excursion o Meperidine (Demerol) is the preferred treatment for acute pain, but all opioids will stimulate the Oddi to some degree o If the gallstone does not dissolve -> abscess, necrosis, and perforation with generalized peritonitis may result  Jaundice: o This can occur when bile obstruction is apparent and is accompanied by pruritus of the skin  Changes in Urine and Stool Color: o Urine will appear very dark, stool is grayish or clay colored  Vitamin Deficiency: o Obstruction interferes with absorption of fat-soluble vitamins: A, D, E, K o Deficiencies in these vitamins could mean obstruction Assessment and Diagnostic Findings  Look at pg. 1432 Table 50-1

Medical Management  Removal of the gallbladder is cholecystectomy  Nutritional and Supportive Care: o Diet after acute episode is low fat liquids. Cooked fruit, rice, lean meats, mashed potatoes, non-gas forming vegetables, bread, coffee, or tea. Avoid eggs, cream, pork, fried foods, cheese, rich dressings, and alcohol.  Pharmacologic Therapy: o With gallstones composed of cholesterol: ursodeoxycholic acid and chenodeoxycholic acid are used to dissolve -> it works by inhibiting the synthesis and secretion of cholesterol thus lowered the saturation levels in bile  6-12 months of therapy  Success rate is low and reoccurrence rate is high o Patients with cystic duct occlusions, pigmented gallstones, or frequent symptoms are not candidates for pharm therapy  Non-surgical Removal of Gallstones: o Dissolving Gallstones: infusion of solvent into gallbladder o Laparoscopic cholecystectomy is the #1 for management o Stone removal by instrument o Intracorporeal Lithotripsy -> fragmented the stones o Extracorporeal Shock Wave Lithotripsy -> nonsurgical fragmentation of stones 

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Surgical Management: o Usually surgery is initiated after patient symptoms have subsided o Use deep breathing and incentive spirometer post op o Laparoscopic Cholecystectomy: standard therapy for gallstones, if bile duct occlusion is suspected this will be explored before surgery, if inflammation occurs during surgery than open surgery is indicated. The most serious concern is bile duct injury resulting in fluid collection and bile peritonitis. Because of shortened hospital stay patient should be educated to report: loss of appetite, vomiting, pain, distention, and temperature elevation. o Cholecystectomy: removal of gallbladder through incision. A drain may be inserted for bile leakage, bile duct injury is serious complication o Small Incision Cholecystectomy: controversy because it limits exposure to all involved biliary structures o Surgical Cholecystectomy: used when the patient needs more extensive surgery or the acute inflammation is severe. Gallbladder is surgically opened and fluid and stones are removed and drainage tube is inserted. Tube is used for bile leakage. High mortality rate due to infection. o Percutaneous Cholecystectomy: used for patients at poor risk for who cannot have general anesthesia. Used with a catheter and needle to decompress the biliary tract Older adults may display symptoms related to sepsis like oliguria, hypotension, changes in mental status, tachycardia, and tachypnea

Nursing Process Assessment:  Avoid aspirin and NSAIDs after surgery because of anti-coagulation  Assess respiratory patterns Diagnosis:  Acute Pain  Impaired Skin Integrity  Impaired Gas Exchange  Imbalanced Nutrition: Less than body requires r/t inadequate bile excretion  Deficient Knowledge

Planning:  Relief of pain  Adequate ventilation  Intact skin and improved biliary drainage  Optimal nutritional intake  Absence of complications  Understanding self care routines Nursing Interventions:  Relieve pain  Improve respiratory status  Maintain skin integrity and promote bile drainage  Improve nutritional status  Monitor and managing potential complications...