History

The patient experiences discomfort after a meal, sometimes with nausea and vomiting, flatulence, and an elevated temperature. An acute attack of cholecystitis is often associated with gallstones, or cholelithiasis. The classic symptom is pain in the right upper quadrant that may radiate to the right scapula, called biliary colic. Onset is usually sudden, with the duration from less than 1 to more than 6 hours. If the flow of bile has become obstructed, the patient may pass clay-colored stools and dark urine.

Physical Exam
The patient with an acute gallbladder attack appears acutely ill, is in a great deal of discomfort, and sometimes is jaundiced. A low-grade fever is often present, especially if the disease is chronic and the walls of the gallbladder have become infected. Right upper quadrant pain is intense in acute attacks, often followed by residual aching or soreness for up to 24 hours. A positive Murphy's sign, which is positive palpation of a distended gallbladder during inhalation, may confirm a diagnosis.

CT Scan

The reported sensitivity and specificity of CT Scan findings are in the range of 9095%. CT is more sensitive than ultrasonography in the depiction of pericholecystic inflammatory response and in localizing pericholecystic abscesses, pericholecystic gas, and calculi outside the lumen of the gallbladder. CT cannot see noncalcified gallbladder calculi, and cannot assess for a Murphy's sign.

BLOOD TEST
Elevated Alkaline Phosphate Elevated Bilirubin (although this may indicate choledocolithiasis ) Elevated WBC count Elevated C-Reactive Protein (CRP) - The degree of elevation of these laboratory values may depend on the degree of inflammation of the gallbladder.

ABDOMINAL ULTRASOUND

Ultrasound has become the diagnostic procedure of choice when evaluating right upper quadrant pain. It is a fast, cheap, and non-invasive way to look at the biliary system and gain insightful information when narrowing a diagnosis. It is particularly good at detecting gallbladder disease and biliary dilatation. Gallstones appear as a highly echogenic focus with acoustic shadows and move to a dependant portion of the gallbladder. Ultrasound can detect stones as small as 1-2mm and has a sensitivity on the order of 95% and a specificity of about 97%.

HIDA

A hepatobiliary iminodiacetic acid (HIDA) scan tracks the production and flow of bile from your liver to your small intestine and shows if bile is blocked at any point along the way. A HIDA scan involves injecting a radioactive chemical into your body. The chemical binds to the bile-producing cells, so it can be clearly seen as it travels with the bile through the bile ducts.

Undergo blood samples and diagnostic tests to determine if you have cholecystitis, as prescribed by the physician. It is more common for people with cholecystitis to be hospitalized and given antibiotics intravenously to prevent infection. Food intake is usually stopped, and intravenous fluids are administered to let the digestive system rest. Correction of electrolyte abnormalities. Bowel rest. Analgesia may be administered for severe abdominal pain.

CHOLECYSTECTOMY

Cholecystectomy is the surgical removal of the gallbladder. It is the most common method for treating symptomatic gallstones. The gallbladder is removed through a 5 to 8 inch long incision, or cut, in your abdomen. The cut is made just below your ribs on the right side and goes to just below your waist. This is called open cholecystectomy.

Laparoscopic cholecystectomy requires several small incisions in the abdomen to allow the insertion of operating ports, small cylindrical tubes approximately 5 to 10 mm in diameter, through which surgical instruments and a video camera are placed into the abdominal cavity.

LAPAROSCOPIC CHOLECYSTECTOMY
A less invasive way to remove the gallbladder. This surgery uses a laparoscope (an instrument used to see the inside of your body) to remove the gallbladder. It is performed through several small incisions rather than through one large incision. It has now replaced open cholecystectomy as the first-choice of treatment for gallstones and inflammation of the gallbladder unless there are contraindications to the laparoscopic approach. This is because open surgery leaves the patient more prone to infection.

Benefits of Laparoscopic Cholecystectomy compared with Open Cholecystectomy: With laparoscopic cholecystectomy, you may return to work sooner, have less pain after surgery, and have a shorter hospital stay and a shorter recovery time. Surgery to remove the gallbladder with a laparoscope does not require that the muscles of your abdomen be cut, as they are in open surgery. The incision is much smaller, which makes recovery go quicker.

With laparoscopic cholecystectomy, you probably will only have to stay in the hospital overnight. With open cholecystectomy, you would have to stay in the hospital for about five days. Because the incisions are smaller with laparoscopic cholecystectomy, there isn't as much pain after this operation as after open cholecystectomy.

Infusion of solvent
Mono-octanoin/ methyl tertiary butyl ether(MTBE) Infused to the bladder Can be infused through a tube or catheter

inserted percutaneous into the bladder to dissolve the gallstones. This involves placement of a double pigtail stent between the gallbladder and the duodenum during endoscopic retrograde cholangiopancreatography (ERCP)

IV Hydration to prevent dehydration in persistent vomiting and avoid oral intake of fluids

Dehydration increases the severity of nausea and vomiting and should be avoided at all cost. When one is unable to take in fluids orally IV therapy becomes necessary. Patient is given fluids intravenously to replace fluids lost through repeated vomiting. Many times these fluids contain electrolytes (i.e., sodium, potassium, chloride) and/or sugars and may be all that is needed to stop a particular term in the cycle of vomiting. Patients admitted for cholecystitis should receive nothing by mouth because of expectant surgery. However, in uncomplicated cholecystitis, a liquid or low-fat diet may be appropriate until the time of surgery.

The individual will not be able to receive food by mouth, and a tube may be passed from the nose into the stomach to keep the stomach empty and prevent stimulation of the gallbladder while providing intravenous hydration.

Ursodeoxycholic

acid (UDCA) and chenodeoxycholic acid (CDCA)

Used to dissolve small, radiolucent gallstones

composed primarily of cholesterol. Acts by inhibiting the synthesis and secretion of cholesterol, thereby desaturating the bile. 6-12 months of drug therapy are required to dissolve the gallstones. This method of treatment is generally indicated for patients who refuse surgery/ surgery is considered too risky.

FOODS TO AVOID
Fatty Foods Cholecystitis sufferers should keep in mind that in this condition , breakdown of fats during digestion is rather difficult. This is because the bile and other digestive juices cannot travel to the stomach and the large intestines, as the gallbladder is blocked due to gallstone formation. As the digestive juices do not mix with food, breakdown of fats, becomes a distant possibility.

FA TTY FOODS THA T SHOULD BE AVOIDED:

Red meat(pork, duck, lamb) Eggs, nuts Dairy products (butter) Fried foods Chocolate and ice cream Beverages like carbonated drinks, coffee or black tea Vegetables such as cabbage and cauliflower

Approximately 80% of the patient with acute gallbladder inflammation achieve remission with rest, intravenous fluid, nasogastric suction, analgesia, and antibiotic agents. Unless the patients condition deteriorates, surgical intervention is delayed until the acute symptoms subside and a complete evaluation can be carried out.

PREVENTION OF INFECTION

PREVENTION OF THE PSYCHOSOCIAL PROBLEMS

Postoperative infectious complications are a frequent cause of morbidity and mortality in the surgical patient. These septic events, which are usually confined to the surgical wound, may involve deeper structures or the bloodstream. The highest incidence of these complications in the patient undergoing elective operations occurs after gastrointestinal surgery, in which the endogenous bacterial populations are usually the causative microorganism

With sufficient support at home, most patient recover quickly from cholecystectomy. However, elderly or frail patients and those who live alone may require a referral for home care. During home visit, assess the patients physical status, especially wound healing, and progress towards recovery. The nurse emphasizes the importance of keeping follow-up appointments and reminds the patient and family of the importance of participating in health promotion activities and recommended health screening.

PREVENTION OF COMPLICATIONS

Bleeding may occur as a result of inadvertent puncture nicking of a major blood vessel. Postoperatively, the nurse closely monitors vital sign and inspect the surgical incision and drains, if in place for evidence of bleeding. The nurse also periodically assesses the patient for increased tenderness and rigidity of the abdomen. If these sign and symptoms occur, they are reported to the surgeon. Instruct the patient and family to report to the surgeon any change in the color of the stools because this may indicate complications.

NURSING DIAGNOSIS: Pain related to increased tension to duodenum.

NURSING DIAGNOSIS: Fluid volume deficit related to restricted fluid intake.

NURSING INTERVENTIONS: Observe and document location, severity (010 scale), and character of pain (e.g., steady, intermittent, colicky). Note response to medication, and report to physician if pain is not being relieved. Promote bed rest, allowing patient to assume position of comfort. Use soft/cotton linens; calamine lotion, oil (Alpha Keri) bath; cool/moist compresses as indicated. Control environmental temperature. Encourage use of relaxation techniques, e.g., guided imagery, visualization, deepbreathing exercises. Provide diversional activities.

NURSING INTERVENTIONS: Check for skin turgor, color, and warmth. Check for dryness in mouth especially for longitudinal furrows on the tongue. Medicate for nausea and vomiting, as ordered by the physician. Administer IV fluids at a rapid rate. Monitor carefully for onset of fluid overload as evidenced by crackles in lungs, dyspnea, and a bounding holes. Document hydration status at regular intervals. Keep accurate intake and output records.

NURSING DIAGNOSIS: Altered nutrition less than body requirements related to high metabolic needs, decreased ability to digest fatty foods.

Ambulate and increase activity as tolerated. Helpful in expulsion of flatus, reduction of abdominal distension. Begin low-fat liquid diet after NG tube is removed.

NURSING INTERVENTIONS: Consult patient about likes/dislikes of foods. Involving patient in planning enables patient to have a distress, and preferred meal schedule, sense of control and encourages eating. Provide a pleasant atmosphere at mealtime Provide oral hygiene before meals. A clean mouth enhances appetite. Offer effervescent drinks with meals, if tolerated. May lessen nausea and relieve gas. Assess for abdominal distension, frequent belching, nonverbal signs of discomfort associated with impaired guarding, and reluctance to move.

NURSING DIAGNOSIS: Altered health maintenance related to knowledge deficit regarding care of disease.

NURSING INTERVENTIONS: Provide explanations of/reasons for test procedures and Information can decrease anxiety, thereby reducing preparation needed. Discuss hospitalization provides knowledge base from which patient can make and prospective treatment as indicated. Encourage informed choices. Discuss weight reduction programs if indicated. 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 or gastric irritants.

Recommend resting in semi-Fowlers position after meals. Promotes flow of bile and general relaxation during initial digestive process. Suggest patient to limit gum chewing, sucking on straw/hard candy, or smoking. Promotes gas formation, which can increase gastric distension/discomfort. Discuss avoidance of aspirin-containing products, forceful Reduces risk of bleeding related to changes in coagulation blowing of nose, straining for bowel movement, contact sports. Recommend use of soft toothbrush, electric razor. time, mucosal irritation, and trauma.

GROUP 8 BSN-3B
Leader: Katherine Valiente Tasniem B. Muti Mae Kenneth Pranza