Care of the Client with Disorders of the Gallbladder ACC RNSG 1247
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Care of the Client with Disorders of the Gallbladder
ACC RNSG 1247
Gallbladder DiseaseTwo main disorders:CholecystitisCholelithiasis
Risk factors for GB diseaseHigher in women: multiparous, over 40, on estrogen therapy Sedentary lifestyleFamilial tendencyObesity
Etiology of CholecystitisAcute : - Calculous: with stone obstruction - Acalculous: absence of stonesChronic: - Repeated attacks, long standing inflammation
Pathophysiology of CholecystitisObstruction leads to ischemia of GB mucosa or wall Inflammation may follow: GB is edematous during acute attack or distended with bile or pusCystic duct may be occludedGB becomes scarred
Clinical Manifestations of Acute vs Chronic CholecystitisWhich are acute signs; which are chronic? ________Usually begins with a biliary colic attackRUQ pain N/VUsually signs of acute inflammationPossible pus formationgangrenous_______Dull acheHistory of fat intoleranceDyspepsiaIncreased flatulence
CholelithiasisCalculi (stones) in the GBMay obstruct the cystic or CBDCholedocholithiasis: stones in the CBDTypes:Composed primarily of pigmentComposed primarily of cholesterol
Pathophysiology of CholelithiasisDevelops when the balance that keeps cholesterol, bile salts and calcium is altered causing precipitation of these substancesConditions affecting balance: infection and altered metabolism of cholesterolBile in GB and liver become saturated with cholesterol
Cholesterol vs Pigment StonesWhich is which & which is more common?______________4x more prevalent in womenformation incidence increased in use of oral contraceptives, estrogens
_____________made of other bile components (bile salts, bilirubin, Ca, protein)undissolvable; requires surgeryincreased risk in: cirrhosis, hemolysis, biliary tree infections
Cholesterol stones 1
Cholesterol stones 2
Clinical Manifestations of CholelithiasisSilent cholelithiasisPain and biliary colicSx RT bile obstruction such as jaundice, pruritus, changes in color of stool and urine, vitamin deficiency, bleeding, steatorrhea
Diagnostic StudiesHistory & physical examinationWould these laboratory tests show increased or decreased levels? * Liver function tests * WBC count * Serum bilirubin * Serum amylase
Diagnostic TestsAbdominal x-raysUltrasonography most accurate HIDA scan Endoscopic retrograde cholangiopancreatography (ERCP)Percutaneous transhepatic cholangiography
Treatment & Nursing CareAcute episodes focus on * Pain control - Morphine - Dilaudid (hydromorphone) - Ketorolac (Toradol) - Demerol (Meperidine) - NSAIDS, anticholinergics * Infection Control - antibiotics
Treatment & Nursing Care continued*Fluid and electrolyte balance - IV fluid - Antiemetics : Metoclopramide (Reglan) Ondansentron (Zofran) Prochlorperazine (Compazine)Gastric Decompression NGT, NPO
*How/what would you monitor to maintain F & E balance?
Treatment and Nursing Care
Once attack is over maintain on_____ fat diet _________ forming foodsAvoid eggs, whole milk products, cheese, ice cream, fried foods, rich foods, alcoholReduced _______ diet if obese
Treatment & Nursing Care:Supportive Drug Therapy * Fat soluble vitamin replacement: A,D,E,K * Bile salts: Ex: Decholin; enhance fat absorption * Bile acids: Exs: Questran and Cholestid; bind bile salts and treat pruritus
Treatment and Nursing Care:Non Surgical Stone Approaches for Stone Removal
* endoscopic sphincterotomy (papillotomy) * mechanical lithotripsy * cholesterol solvents * extracorporeal shock wave lithotripsy
ERCP with Sphincterectomy
Treatment and Nursing Care: SurgicalWhen is one preferred over another? Why? ____________ Cholecystectomy * GB removed through 4 puncture holes * CX: injury to CBD _________Cholecystectomy * removal of GB via right subcostal incision * T tube inserted into CBD
Laparoscopic vs Open Cholestectomy
Treatment and Nursing Care:Surgical Transhepatic biliary catheter * to decompress obstructed extrahepatic ducts
Treatment and Nursing Care: Post Op Care &TeachingsPain ControlPrevent Complications primarily pulmonaryWound CareDietary modification
Gerontologic considerationsGallstones increasingly commonDiffering presenting symptomsSurgical risks due to concurrent conditionsDecreased elective surgery and more advanced status at time of surgeryHigher risk of complications and shorter hospital stays
Gallbladder Cancer UncommonMajority are adenocarcinomasEarly symptoms similar to chronic cholecystitis and cholelithiasisLater symptoms of biliary obstructionPoor prognosis
Gallbladder CancerDiagnosis and staging EUS, transabdominal US, CT, MRI, MRCPIf found early surgery is curativeExtended cholestectomy with lymph node dissection good outcomePalliative stenting of biliary tree, radiation, chemotherapy
Gallbladder CancerNursing Management - supportive careNutrition, hydration, skin care, pain reliefSimilar to care for cholecystitis and cholelithiasis and cancer
Altered bile flow through the hepatic, cystic, or common bile duct is a common problem. It often leads to inflammation and other complications. Gallstones are the most common cause of obstructed flow. Tumors and abscesses also can obstruct the bile flow.*Located in the RUQ: identify the CBD in this photo*After 60, GB is 10-15% higher in men; 20-40% higher in womenOften seasonal: higher incidence in winter, esp, during the holidays!*
Acute : - Calculous: with stone obstruction; Commonly follows Cystic duct obstruction by a stone; more common cause - Acalculous: absence of stones or obstruction; May be found in older adults, those who sustained trauma, recent surgery, immobility, or bacteria primarily E. coli
Chronic: - Repeated attacks, long standing inflammation
*RUO pain radiates to back, R scapula and shoulder, can last for 12-18 hours. Pain particularly after a fatty mealBiliary colic steady upper abdominal pain*Bile becomes supersaturated with cholesterol due to decrease in bile acid synthesis and increased cholesterol synthesis in liver.
*Their brown and green color in color*Biliary stonesSilent cholelithiasis no sx when gallstones are stationary in GB
Pain and biliary colic stones are moving thru the ducts cystic, duct then CBD; pain maybe accompanied by tachycardia, and diaphoresis, may last up to an hour
Attacks of pain usually occurs 3-6 hrs after a heavy meal or in the middle of the night.
** Which organ will be affected next as the obstruction moves on further down the biliary tree?
** Where do you think would the stones be in chronic cholecystitis, in acute chole?*LFT High AST,ALST, alkaline phosphatseWBC- highSerum bilirubin high if with obstructionSerum amylase high if pancreas involved*US 90-95 % accurate in detecting stones; confirms presence of stones and whether stones are in GB or cystic duct
HIDA scan if Sx are present but other tests fail to show stones ERCP visualizes GB, CD, CHD, CBD. Culture is sent to ID infecting organisms
Percutaneous transhepatic cholangiography are use to diagnose obstructive jaundice and locate stones within the bile ducts*Treatment is supportive and symptomatic.
Anticholinergics to decrease secretions and counteract muscle spasmsGastric decompression if w/ nausea. vomiting.
*Nursing precautions pre and post procedure;
Pre - NPOPost monitor VS, minimal RF aspiration, painQUESTIONS
When is one preferred over another? Lap chole is the treatment of choice for uncomplicated cases.
Advantages of lap chole? Minimal post-op pain generally, same or next day DC
When is open chole preferred? Open chole is used when there is biliary obstruction and liver dysfunction. GB is removed through a right subcostal incision.
T tube: = ensures patency of the duct until edema from procedure has subsided = allows excess bile to drain
4. Can lap chole lead to open chole?*Placement of t-tube. Dotted line indicate parts removed. T tube is connected to gravity darinage.
Nursing care: monitor drainage from t tube*Transhepatic biliary catheter: = inserted percuataneously = after insertion, catheter is connected to drainage bag*Low fat diet, reduced calorie as well if obese