Cholelithiasis

Question 1

Cholelithiasis

Answer 1

Stones in gallbladder

Most common disorder of biliary system

Question 2

Risk factors

Answer 2

Female
Multiparity
Age older than 40 years
Estrogen therapy
Sedentary lifestyle
Genetics/ethnicity
Obesity

Question 3

Etiology and patho

Answer 3

Cause of gallstones is unknown
Develops when balance that keeps cholesterol, bile salts, and calcium in solution is altered
Stasis of bile - sludge
Decreased bile flow

Question 4

Clinical manifestations

Answer 4

Vary from severe to none at all
Pain more severe when stones moving or obstructing
-Steady, excruciating
-Tachycardia, diaphoresis, prostration
-May be referred to shoulder/scapula
-Residual tenderness in RUQ
-Occurs 3-6 hrs after high-fat meal or when patient lies down

Question 5

Total obstruction symptoms

Answer 5

Jaundice
Dark amber urine
Clay-colored stools
Pruritus
Intolerance of fatty foods
Bleeding tendencies
Steatorrhea

Question 6

Diagnostic Studies

Answer 6

Ultrasonography
ERCP
PTC

Question 7

Blood work - Lab findings

Answer 7

Increased:

• WBC Count
• Serum bilirubin level
• Liver enzyme levels
• Serum amylase level

Question 8

Collaborative Care

Answer 8

Oral dissolution therapy (ursodeoxycholic acid, chenodeoycholic acid)
ERCP w/ sphincterotomy
Transhepatic biliary catheter: to train purulent material
Extracorproeal shock-wave lithotripsy (ESWL)

Question 9

Cholecystectomy (laparoscopic)

Answer 9

Treatment of choice
Removal of gallbladder through one to four puncture holes
Minimal postoperative pain
Resume normal activities, including work within 1 week
Few complications
AFTER:
-Liquids first day
-Light meals for several days

Question 10

Open (incisional) cholecystectomy

Answer 10

Removal of gallbladder through right subcostal incision
T-tube inserted into common bile duct
-ensures patency of duct
-allows excess bile to drain
AFTER:
-Liquids to regular diet after return of bowel sounds
-May need to restrict fats for 4-6 weeks

Question 11

Nutritional Therapy

Answer 11

Small, frequent meals w/ some fat
Diet low in saturated fat
High in fiber and calcium
Reduced-calorie diet if patient is obese
Avoidance of rapid weight loss

Question 12

Overall goals

Answer 12

Relief of pain and discomfort
No complications postoperatively
No recurrent attacks of cholecystitis or cholelithiasis

Question 13

Health Promotion

Answer 13

Screen for predisopsing factors
Teaching for at-risk ethnic groups
Early detection of chronic cholecystitis
-Manage w/ low-fat diet

Question 14

Nursing Goals

Answer 14

Relieve pain
Relieve nausea and vomiting
Provide comfort and emotional support
Maintain fluid and electrolyte balance/nutrition
Accurate assessments
Monitor for complications

Question 15

Acute interventions

Answer 15

Pain management
Comfort measures
Manage N/V
Pruritus relief measures
Monitor for complications
-Obstruction
-Bleeding
-Infection

Question 16

Postoperative care for laparoscopic cholecystectomy

Answer 16

Monitor for complications
Patient comfort
Clear liquids
Discharged same day
HOME CARE:
Removal of bandages day after surgery, then can shower
Report signs of infection
Gradually resume activities
Return to work in 1 week
May need low-fat diet for several weeks

Question 17

Postoperative care for incisional cholecystectomy

Answer 17

Maintain adequate ventilation
Prevent respiratory complications
General postoperative nursing care
Maintain drainage tubes (T-tube, Penrose tube, Jackson-Pratt tube) if present
HOME CARE:
Discharged in 2-3 days
No heavy lifting for 4-6 weeks
Usual activities when feeling ready
May need low-fat diet for 4-6 weeks

Question 18

Ambulatory and home care

Answer 18

Diet teaching
-low-fat diet
-weight reduction if needed
-fat-soluble vitamin supplements
Teach what to report
Follow-up care

Question 19

Expected outcomes

Answer 19

Appear comfortable and verbalize pain relief

Verbalize knowledge of activity level and dietary restrictions