CHOLECYSTITIS WITH CHOLELITHIASIS

Cholecystitis is an acute or chronic inflammation of the gallbladder, usually associated with gallstone(s) impacted in the cystic
duct, causing distension of the gallbladder. 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.
CARE SETTING
Severe acute attacs may re!uire brief hospitali"ation on a medical unit. #his plan of care deals with the acutely ill, hospitali"ed
patient.
RELATED CONCERNS
Cholecystectomy
$luid and electrolyte imbalances, see %ursing &lan C'()*+
&sychosocial aspects of care
#otal nutritional support, parenteral-enteral feeding
Patient Assessment Database
ACTIVITY/REST
May report:$atigue
May exhibit:)estlessness
CIRCULATION
May exhibit:#achycardia, diaphoresis, lightheadedness
ELIMINATION
May report:Change in color of urine and stools
May exhibit:Abdominal distension
&alpable mass in right upper !uadrant ()./)
'ar, concentrated urine
Clay(colored stool, steatorrhea
FOOD/FLUID
May report:Anorexia, nausea-vomiting
0ntolerance of fatty and 1gas(forming2 foods3 recurrent regurgitation, heartburn,
indigestion, flatulence, bloating (dyspepsia)
4elching (eructation)
May exhibit:*besity3 recent weight loss
%ormal to hypoactive bowel sounds
PAIN/DISCOMFORT
May report:Severe epigastric and right upper abdominal pain, may radiate to mid(bac, right shoulder-scapula, or to front
of chest
+idepigastric colicy pain associated with eating, especially after meals rich in fats
&ain severe-ongoing, starting suddenly, sometimes at night, and usually peaing in 56
min, often increases with movement
)ecurring episodes of similar pain
May exhibit:)ebound tenderness, muscle guarding, or abdominal rigidity when )./ is palpated3 positive +urphy7s sign
RESPIRATION
May exhibit:0ncreased respiratory rate
Splinted respiration mared by short, shallow breathing
SAFETY
May exhibit:8ow(grade fever3 high(grade fever and chills (septic complications)
9aundice, with dry, itching sin (pruritus)
4leeding tendencies (vitamin : deficiency)
TEACHING/LEARNING
May report:$amilial tendency for gallstones
)ecent pregnancy-delivery3 history of diabetes mellitus ('+), 04', blood dyscrasias
Dischare p!an DRG projected mean length of inpatient stay: 4.3 days
consi"erations:+ay re!uire support with dietary changes-weight reduction
Refer to section at end of plan for postdischarge considerations.
DIAGNOSTIC STUDIES
Biliary ultrasound: )eveals calculi, with gallbladder and-or bile duct distension (fre!uently the initial diagnostic procedure).
Oral cholecystography (OCG): &referred method of visuali"ing general appearance and function of gallbladder, including
presence of filling defects, structural defects, and-or stone in ducts-biliary tree. Can be done 0; (0;C) when
nausea-vomiting prevent oral intae, when the gallbladder cannot be visuali"ed during *CG, or when symptoms persist
following cholecystectomy. 0;C may also be done perioperatively to assess structure and function of ducts, detect
remaining stones after lithotripsy or cholecystectomy, and-or to detect surgical complications. 'ye can also be in<ected via
#(tube drain postoperatively.
Endoscopic retrograde cholangiopancreatography (ERCP): ;isuali"es biliary tree by cannulation of the common bile duct
through the duodenum.
Percutaneous transhepatic cholangiography (PTC): $luoroscopic imaging distinguishes between gallbladder disease and cancer
of the pancreas (when <aundice is present)3 supports the diagnosis of obstructive <aundice and reveals calculi in ducts.
Cholecystograms (for chronic cholecystitis): )eveals stones in the biliary system. Note: Contraindicated in acute cholecystitis
because patient is too ill to tae the dye by mouth.
Nonnuclear CT scan: +ay reveal gallbladder cysts, dilation of bile ducts, and distinguish between obstructive-nonobstructive
<aundice.
epato!iliary ("#$% P"P"#$) scan: +ay be done to confirm diagnosis of cholecystitis, especially when barium studies are
contraindicated. Scan may be combined with cholecystoinin in<ection to demonstrate abnormal gallbladder e<ection.
$!dominal &'ray films (multipositional): )adiopa!ue (calcified) gallstones present in =6>?=@> of cases3 calcification of the
wall or enlargement of the gallbladder.
Chest &'ray: )ule out respiratory causes of referred pain.
CBC: +oderate leuocytosis (acute).
(erum !iliru!in and amylase: Alevated.
(erum li)er en*ymes+$(T, $-T, $-P, -#: Slight elevation3 alaline phosphatase and @(nucleotidase are maredly elevated
in biliary obstruction.
Prothrom!in le)els: )educed when obstruction to the flow of bile into the intestine decreases absorption of vitamin :.
NURSING PRIORITIES
=. )elieve pain and promote rest.
B. +aintain fluid and electrolyte balance.
5. &revent complications.
C. &rovide information about disease process, prognosis, and treatment needs.
DISCHARGE GOALS
=. &ain relieved.
B. Domeostasis achieved.
5. Complications prevented-minimi"ed.
C. 'isease process, prognosis, and therapeutic regimen understood.
@. &lan in place to meet needs after discharge
#$%SI#& DIA&#OSIS: Pain' ac(te
May be re!ate" to
4iological in<uring agents, obstruction-ductal spasm, inflammatory process, tissue ischemia-necrosis
Possib!y e)i"ence" by
)eports of pain, biliary colic (waves of pain)
$acial mas of pain3 guarding behavior
Autonomic responses (changes in 4&, pulse)
Self(focusing3 narrowed focus
DESI%ED O$TCOMES*E+AL$ATIO# C%ITE%IA,PATIE#T WILL:
Pain Contro! -#OC.
)eport pain is relieved-controlled.
'emonstrate use of relaxation sills and diversional activities as indicated for individual situation.
ACTIONS/INTERVENTIONS
Pain Manaement -#IC.
In"epen"ent
*bserve and
document
location,
severity (6?=6
scale), and
character of
pain (e.g.,
steady,
intermittent,
colicy).
%ote response
to medication,
and report to
physician if
pain is not
being relieved.
RATIONALE
Assists in
differentiating
cause of pain,
and provides
information
about disease
progression-res
olution,
development of
complications,
and
effectiveness of
interventions.
Severe pain not
relieved by
&romote
bedrest,
allowing
patient to
assume
position of
comfort.
.se soft-cotton
linens3
calamine
lotion, oil
(Alpha :eri)
bath3
cool-moist
compresses as
indicated.
Control
environmental
temperature.
Ancourage use
of relaxation
techni!ues,
e.g., guided
imagery,
routine
measures may
indicate
developing
complications-
need for further
intervention.
4edrest in low(
$owler7s
position
reduces intra(
abdominal
pressure3
however,
patient will
naturally
assume least
painful
position.
)educes
irritation-dryne
ss of the sin
and itching
sensation.
Cool
surroundings
aid in
minimi"ing
dermal
discomfort.
visuali"ation,
deep(breathing
exercises.
&rovide
diversional
activities.
+ae time to
listen to and
maintain
fre!uent
contact with
patient.
&romotes rest,
redirects
attention, may
enhance
coping.
Delpful in
alleviating
anxiety and
refocusing
attention,
which can
relieve pain.
ACTIONS/INTERVENTIONS
Pain Manaement -#IC.
Co!!aborati)e
+aintain %&* status, insert-maintain %G suction as
indicated.
Administer medications as indicated,
Anticholinergics, e.g., atropine, propantheline (&ro(
4anthE(ne)3
Sedatives, e.g., phenobarbital3
%arcotics, e.g., meperidine hydrochloride ('emerol),
morphine sulfate3
+onoctanoin (+octanin)3
Smooth muscle relaxants, e.g., papaverine (&avabid),
nitroglycerin, amyl nitrite3
Chenodeoxycholic acid (Chenix), ursodeoxycholic acid
(.rso, Actigall)3
Antibiotics.
&repare for procedures, e.g.,
Andoscopic papillotomy (removal of ductal stone)3
Axtracorporeal shoc wave lithotripsy (ASF8)3
Andoscopic sphincterotomy3
RATIONALE
)emoves gastric secretions that stimulate release of
cholecystoinin and gallbladder contractions.
)elieves reflex spasm-smooth muscle contraction and
assists with pain management.
&romotes rest and relaxes smooth muscle, relieving pain.
Given to reduce severe pain. +orphine is used with caution
because it may increase spasms of the sphincter of *ddi,
although nitroglycerin may be given to reduce morphine(
induced spasms if they occur.
#his medication may be used after a cholecystectomy for
retained stones or for newly formed large stones in the bile
duct. 0t is a lengthy treatment (=?5 w) and is administered
via a nasal(biliary tube. A cholangiogram is done
periodically to monitor stone dissolution.
)elieves ductal spasm.
#hese natural bile acids decrease cholesterol synthesis,
dissolving gallstones. Success of this treatment depends on
the number and si"e of gallstones (preferably three or fewer
stones smaller than B6 min in diameter) floating in a
functioning gallbladder.
#o treat infectious process, reducing inflammation.
Choice of procedure is dictated by individual situation.
Shoc wave treatment is indicated when patient has mild or
moderate symptoms, cholesterol stones in gallbladder are
6.@ mm or larger, and there is no biliary tract obstruction.
'epending on the machine being used, the patient may sit in
a tan of water or lie prone on a water(filled cushion.
#reatment taes about =?B hr and is G@>?H@> successful.
Note: #his procedure is contraindicated in patients with
pacemaers or implantable defibrillators.
&rocedure done to widen the mouth of the common bile duct
where it empties into the duodenum. #his procedure may
also include the manual retrieval of stones from the duct by
means of a tiny baset or balloon on the end of the
endoscope. Stones must be smaller than =@ mm.
ACTIONS/INTERVENTIONS
Pain Manaement -#IC.
Co!!aborati)e
Surgical
intervention.
RATIONALE
Cholecystecto
my may be
indicated
because of
the si"e of
stones and
degree of
tissue
involvement-
presence of
necrosis.
)efer to C&,
Cholecystecto
my.
#$%SI#& DIA&#OSIS: /!(i" +o!(me' ris0 1or "e1icient
%is0 1actors may inc!("e
Axcessive losses through gastric suction3 vomiting, distension, and gastric hypermotility
+edically restricted intae
Altered clotting process
Possib!y e)i"ence" by
I%ot applicable3 presence of signs and symptoms and establishes an actual diagnosis.J
DESI%ED O$TCOMES*E+AL$ATIO# C%ITE%IA,PATIE#T WILL:
Hy"ration -#OC.
'emonstrate ade!uate fluid balance evidenced by stable vital signs, moist mucous membranes, good sin turgor,
capillary refill, individually appropriate urinary output, absence of vomiting.
ACTIONS/INTERVENTIONS
/!(i"*E!ectro!yte Manaement -#IC.
In"epen"ent
+aintain accurate record of 0K*, noting output less than
intae, increased urine specific gravity. Assess sin-mucous
membranes, peripheral pulses, and capillary refill.
+onitor for signs-symptoms of increased-continued nausea
or vomiting, abdominal cramps, weaness, twitching,
sei"ures, irregular heart rate, paresthesia, hypoactive or
absent bowel sounds, depressed respirations.
Aliminate noxious sights-smells from environment.
&erform fre!uent oral hygiene with alcohol(free
mouthwash3 apply lubricants.
RATIONALE
&rovides information about fluid status-circulating volume
and replacement needs.
&rolonged vomiting, gastric aspiration, and restricted oral
intae can lead to deficits in sodium, potassium, and
chloride.
.se small(gauge needles for in<ections and apply firm
pressure for longer than usual after venipuncture.
)educes stimulation of vomiting center.
'ecreases dryness of oral mucous membranes3 reduces ris
of oral bleeding.
)educes trauma, ris of bleeding-hematoma formation.
ACTIONS/INTERVENTIONS
/!(i"*E!ectro!yte Manaement -#IC.
In"epen"ent
Assess for unusual bleeding, e.g., oo"ing from in<ection
sites, epistaxis, bleeding gums, ecchymosis, petechiae,
hematemesis-melena.
Co!!aborati)e
:eep patient %&* as necessary.
0nsert %G tube, connect to suction, and maintain patency as
indicated.
Administer antiemetics, e.g., prochlorpera"ine (Compa"ine).
)eview laboratory studies, e.g., Db-Dct, electrolytes, A4Gs
(pD), clotting times.
Administer 0; fluids, electrolytes, and vitamin :.
RATIONALE
&rothrombin is reduced and coagulation time prolonged
when bile flow is obstructed, increasing ris of
bleeding-hemorrhage.
'ecreases G0 secretions and motility.
&rovides rest for G0 tract.
)educes nausea and prevents vomiting.
Aids in evaluating circulating volume, identifies deficits,
and influences choice of intervention for
replacement-correction.
+aintains circulating volume and corrects imbalances.
#$%SI#& DIA&#OSIS: #(trition: imba!ance"' ris0 1or !ess than bo"y re2(irements
%is0 1actors may inc!("e
Self(imposed or prescribed dietary restrictions, nausea-vomiting, dyspepsia, pain
8oss of nutrients3 impaired fat digestion due to obstruction of bile flow
Possib!y e)i"ence" by
I%ot applicable3 presence of signs and symptoms establishes an actual diagnosis.J
DESI%ED O$TCOMES*E+AL$ATIO# C%ITE%IA,PATIE#T WILL:
#(tritiona! Stat(s -#OC.
)eport relief of nausea-vomiting.
'emonstrate progression toward desired weight gain or maintain weight as individually appropriate.
ACTIONS/INTERVENTIONS
#(trition Manaement -#IC.
In"epen"ent
Astimate-calculate caloric intae. :eep comments about
appetite to a minimum.
RATIONALE
0dentifies nutritional deficiencies-needs. $ocusing on
problem creates a negative atmosphere and may interfere
with intae.
ACTIONS/INTERVENTIONS
#(trition Manaement -#IC.
In"epen"ent
Feigh as indicated.
Consult with patient about lies-dislies, foods that cause
distress, and preferred meal schedule.
&rovide a pleasant atmosphere at mealtime3 remove noxious
stimuli.
&rovide oral hygiene before meals.
*ffer effervescent drins with meals, if tolerated.
Assess for abdominal distension, fre!uent belching,
guarding, reluctance to move.
Ambulate and increase activity as tolerated.
Co!!aborati)e
Consult with dietitian-nutritional support team as indicated.
4egin low(fat li!uid diet after %G tube is removed.
Advance diet as tolerated, usually low(fat, high(fiber.
)estrict gas(producing foods (e.g., onions, cabbage,
popcorn) and foods-fluids high in fats (e.g., butter, fried
foods, nuts).
Administer bile salts, e.g., 4ilron, Lanchol, dehydrocholic
acid ('echolin), as indicated.
+onitor laboratory studies, e.g., 4.%, prealbumin,
albumin, total protein, transferrin levels.
&rovide parenteral-enteral feedings as needed.
RATIONALE
+onitors effectiveness of dietary plan.
0nvolving patient in planning enables patient to have a sense
of control and encourages eating.
.seful in promoting appetite-reducing nausea.
A clean mouth enhances appetite.
+ay lessen nausea and relieve gas. Note: +ay be
contraindicated if beverage causes gas formation-gastric
discomfort.
%onverbal signs of discomfort associated with impaired
digestion, gas pain.
Delpful 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 He.g., pneumonia, thrombophlebitis).
.seful in establishing individual nutritional needs and most
appropriate route.
8imiting fat content reduces stimulation of gallbladder and
pain associated with incomplete fat digestion and is helpful
in preventing recurrence.
+eets nutritional re!uirements while minimi"ing
stimulation of the gallbladder.
&romotes digestion and absorption of fats, fat(soluble
vitamins, cholesterol. .seful in chronic cholecystitis.
&rovides information about nutritional deficits-effectiveness
of therapy.
Alternative feeding may be re!uired depending on degree of
disability-gallbladder involvement and need for prolonged
gastric rest.
#$%SI#& DIA&#OSIS: 3no4!e"e' "e1icient 5Learnin #ee"6 rear"in con"ition' pronosis'
treatment' se!17care' an" "ischare nee"s
May be re!ate" to
8ac of nowledge-recall
0nformation misinterpretation
.nfamiliarity with information resources
Possib!y e)i"ence" by
/uestions3 re!uest for information
Statement of misconception
0naccurate follow(through of instruction
'evelopment of preventable complications
DESI%ED O$TCOMES*E+AL$ATIO# C%ITE%IA,PATIE#T WILL:
3no4!e"e: I!!ness Care -#OC.
;erbali"e understanding of disease process, prognosis, potential complications.
;erbali"e understanding of therapeutic needs.
0nitiate necessary lifestyle changes and participate in treatment regimen.
ACTIONS/INTERVENTIONS
Teachin: Disease Process -#IC.
In"epen"ent
&rovide explanations of-reasons for test procedures and
preparation needed.
)eview disease process-prognosis. 'iscuss hospitali"ation
and prospective treatment as indicated. Ancourage
!uestions, expression of concern.
)eview drug regimen, possible side effects.
RATIONALE
0nformation can decrease anxiety, thereby reducing
sympathetic stimulation.
&rovides nowledge base from which patient can mae
informed choices. Affective communication and support at
this time can diminish anxiety and promote healing.
'iscuss weight reduction programs if indicated
0nstruct patient to avoid food-fluids high in fats (e.g., whole
mil, ice cream, butter, fried foods, nuts, gravies, por), gas
producers (e.g., cabbage, beans, onions, carbonated
beverages), or gastric irritants (e.g., spicy foods, caffeine,
citrus).
Gallstones often recur, necessitating long(term therapy.
'evelopment of diarrhea-cramps during chenodiol therapy
may be dose(related-correctable. Note: Fomen of
childbearing age should be counseled regarding birth control
to prevent pregnancy and ris of fetal hepatic damage.
*besity is a ris factor associated with cholecystitis, and
weight loss is beneficial in medical management of chronic
condition.
&revents-limits recurrence of gallbladder attacs.
ACTIONS/INTERVENTIONS
Teachin: Disease Process -#IC.
In"epen"ent
)eview signs-symptoms re!uiring medical intervention,
e.g., recurrent fever3 persistent nausea-vomiting, or pain3
<aundice of sin or eyes, itching3 dar urine3 clay(colored
stools3 blood in urine, stools, vomitus3 or bleeding from
mucous membranes.
)ecommend resting in semi($owler7s position after meals.
Suggest patient limit gum chewing, sucing on straw-hard
candy, or smoing.
'iscuss avoidance of aspirin(containing products, forceful
blowing of nose, straining for bowel movement, contact
sports. )ecommend use of soft toothbrush, electric ra"or.
RATIONALE
0ndicative of progression of disease process-development of
complications re!uiring further intervention.
&romotes flow of bile and general relaxation during initial
digestive process.
&romotes gas formation, which can increase gastric
distension-discomfort.
)educes ris of bleeding related to changes in coagulation
time, mucosal irritation, and trauma.
POTE#TIAL CO#SIDE%ATIO#S 1o!!o4in ac(te hospita!i8ation -"epen"ent on patient9s ae' physica!
con"ition*presence o1 comp!ications' persona! reso(rces' an" !i1e responsibi!ities.
&ain, acuteMrecurrence of obstruction-ductal spasm3 inflammation, tissue ischemia.