Advanced Concept of Nursing- IIUNIT- V

Advance Nursing Managementof GIT diseases.

Cholecystitis.

In The Name of God

(A PROJECT OF NEW LIFE HEALTH CARE SOCIETY, KARACHI)

UNIT- VAdvance Nursing Management

of GIT diseases.

Cholecystitis.Shahzad Bashir

RN, BScN, DCHN,MScN (Std.DUHS)Instructor

New Life College of NursingUpdated on June 08, 2016

Objectives:By the end of this presentation, the students willbe able to:

Define cholecyctitis. Discuss the pathophysiology of cholecystitis. List the types of cholecystitis. Identify the clinical features of cholecystitis. Elaborate the investigations of cholecystitis. Explain the medical and nursing management

of cholecyctitis. Cite nursing diagnosis of cholecyctitis.

Define cholecyctitis. Discuss the pathophysiology of cholecystitis. List the types of cholecystitis. Identify the clinical features of cholecystitis. Elaborate the investigations of cholecystitis. Explain the medical and nursing management

of cholecyctitis. Cite nursing diagnosis of cholecyctitis.

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Gallbladder When food enters the duodenum, the gallbladder contracts and the sphicter

of Oddi relaxes (valve in the common bile duct), allowing bile to enter theintestine.

Cholecystitis - inflammation of gallbladder usually develops in assoc. withgallstones. But can occur from bacterial invasion or biliary spasm. Jaundice,bile obstruction not common. Blockage of bile flow from GB

Gallbladder becomes fibrotic and contracted, which result in decreasedmotility and deficient absorption.

3x4” pear shaped hollow organ underside of liver

Cholilithiasis- over time the concentration of bile in the gallbladder mayresult in insoluble stones, especially if bile contains high amounts ofcholesterol.

When food enters the duodenum, the gallbladder contracts and the sphicterof Oddi relaxes (valve in the common bile duct), allowing bile to enter theintestine.

Cholecystitis - inflammation of gallbladder usually develops in assoc. withgallstones. But can occur from bacterial invasion or biliary spasm. Jaundice,bile obstruction not common. Blockage of bile flow from GB

Gallbladder becomes fibrotic and contracted, which result in decreasedmotility and deficient absorption.

3x4” pear shaped hollow organ underside of liver

Cholilithiasis- over time the concentration of bile in the gallbladder mayresult in insoluble stones, especially if bile contains high amounts ofcholesterol.

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Conti….

Cholesterol stones form and block drainage of bilefrom gallbladder, which causes spasm, GBbecomes inflamed, edematous and distended. Thiscongestion leads to changes in GB circulationwhich eventually causes necrosis. Bacterialgrowth also develops.

Cholesterol stones form and block drainage of bilefrom gallbladder, which causes spasm, GBbecomes inflamed, edematous and distended. Thiscongestion leads to changes in GB circulationwhich eventually causes necrosis. Bacterialgrowth also develops.

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Gallbladder

Function- storage depot for bile Cholecystitis- inflammation of the

gallbladder wall, acute infection Cholelithiasis - presence of gallstones

Function- storage depot for bile Cholecystitis- inflammation of the

gallbladder wall, acute infection Cholelithiasis - presence of gallstones

Cholecystitis

Inflammation of gallbladder is called ascholecystitis.

Two types of cholecystitis.

Acute cholecystitis Chronic cholecyctitis

Inflammation of gallbladder is called ascholecystitis.

Two types of cholecystitis.

Acute cholecystitis Chronic cholecyctitis

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Acute cholecystitis

Acute cholecystitis is acute inflammation of gallbladder.

It is precipitated 90% of time by gallstones obstructionof neck or cystic duct.

Acalculous cholecystitis describes acute gallbladderinflammation in the absence of obstruction bygallstones.

For example: Surgical procedure, sever trauma, severeburns etc.

Acute cholecystitis is acute inflammation of gallbladder.

It is precipitated 90% of time by gallstones obstructionof neck or cystic duct.

Acalculous cholecystitis describes acute gallbladderinflammation in the absence of obstruction bygallstones.

For example: Surgical procedure, sever trauma, severeburns etc.

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Clinical features

Right upper quadrant pain Pain radiates to right scapula and right shoulder Fever Anorexia Tachycardia Diaphoresis Nausea & vomiting Jaundice

Right upper quadrant pain Pain radiates to right scapula and right shoulder Fever Anorexia Tachycardia Diaphoresis Nausea & vomiting Jaundice

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Pathophysiology (Calculus Cholecystitis) A gallbladder stone obstructs bile outflow.

Bile remaining in the gallbladder initiates a chemicalreaction.

It causes autolysis and edema

The blood vessels in the gallbladder are compressed,compromising its vascular supply.

Gangrene of gallbladder with perforation may result.

Bacteria play a minor role in acute Cholecystitis .i.e.Enterococci, Staphylococci , E. coli

A gallbladder stone obstructs bile outflow.

Bile remaining in the gallbladder initiates a chemicalreaction.

It causes autolysis and edema

The blood vessels in the gallbladder are compressed,compromising its vascular supply.

Gangrene of gallbladder with perforation may result.

Bacteria play a minor role in acute Cholecystitis .i.e.Enterococci, Staphylococci , E. coli

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Pathophysiology (Acalculus Cholecystitis) Acalculous Cholecystitis describes acute

gallbladder inflammation in the absence ofobstruction by gallstones.

Acalculous Cholecystitis occurs after majorsurgical procedures, severe trauma, or burns

It results from alterations in fluids andelectrolytes and in regional blood flow in thevisceral circulation.

Acalculous Cholecystitis describes acutegallbladder inflammation in the absence ofobstruction by gallstones.

Acalculous Cholecystitis occurs after majorsurgical procedures, severe trauma, or burns

It results from alterations in fluids andelectrolytes and in regional blood flow in thevisceral circulation.

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Cholecystitis: Pathophysiology The most common cause is cholelithiasis; obstructing the cystic and

or common bile ducts.

Can be acute or chronic

Bile is used for digestion of fats. It’s produced in the liver and storedin the gallbladder. When the concentration of bilirubin in the bloodincreases to greater than 2mg/dl, jaundice occurs.

Acute- gallstones partially/completely obstruct CBD

Chronic Cholecystitis- results from inefficient emptying of bile bygallbladder and gallbladder muscle wall disease persists.

Chronic- may be caused by or lead to formation of gallstones(cholelithiasis)

The most common cause is cholelithiasis; obstructing the cystic andor common bile ducts.

Can be acute or chronic

Bile is used for digestion of fats. It’s produced in the liver and storedin the gallbladder. When the concentration of bilirubin in the bloodincreases to greater than 2mg/dl, jaundice occurs.

Acute- gallstones partially/completely obstruct CBD

Chronic Cholecystitis- results from inefficient emptying of bile bygallbladder and gallbladder muscle wall disease persists.

Chronic- may be caused by or lead to formation of gallstones(cholelithiasis)

Investigations

Ultrasonography The use of ultrasound is based on reflected

sound waves.

Ultrasonography can detect calculi in thegallbladder or a dilated common bile duct.

To detect gallstones with 95% accuracy.

Ultrasonography The use of ultrasound is based on reflected

sound waves.

Ultrasonography can detect calculi in thegallbladder or a dilated common bile duct.

To detect gallstones with 95% accuracy.

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Cholescintigraphy

Cholescintigraphy is used successfully in thediagnosis of acute cholecystitis

A radioactive agent (Technitum 99-M) isadministered intravenously

It is taken up by the hepatocytes and excretedrapidly through the biliary tract

The biliary tract is then scanned, and images ofthe gallbladder and biliary tract are obtained

Cholescintigraphy is used successfully in thediagnosis of acute cholecystitis

A radioactive agent (Technitum 99-M) isadministered intravenously

It is taken up by the hepatocytes and excretedrapidly through the biliary tract

The biliary tract is then scanned, and images ofthe gallbladder and biliary tract are obtained

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Nursing Diagnosis

Altered nutrition: less than body requirementrelated to inadequate bile secretion

Deficient knowledge related to dietarymodifications, medications, self care activities

Acute pain related to inflammation of gallbladder Impaired skin integrity related to vomiting Risk for infection Knowledge deficit

Altered nutrition: less than body requirementrelated to inadequate bile secretion

Deficient knowledge related to dietarymodifications, medications, self care activities

Acute pain related to inflammation of gallbladder Impaired skin integrity related to vomiting Risk for infection Knowledge deficit

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Nursing InterventionsS/P CholecystectomyLap vs. Open CholecystecomyLOCVital signsPulmonary Hygiene (cough deep breath, ambulate, turnand position incentive spirometer)Splinting to reduce painPain managementMonitor wound incision /S/S of infectionMonitor T-tube drainage (initially bloody, then green-brown bile)T-tube initially may drain >400ml/day then shouldgradually decrease

Lap vs. Open CholecystecomyLOCVital signsPulmonary Hygiene (cough deep breath, ambulate, turnand position incentive spirometer)Splinting to reduce painPain managementMonitor wound incision /S/S of infectionMonitor T-tube drainage (initially bloody, then green-brown bile)T-tube initially may drain >400ml/day then shouldgradually decrease

Care of the T-tube

Report sudden increases in drainage or amountsexceeding 1000ml/day

Keep drainage bag below level of GB Inspect surrounding skin Maintain flow by gravity Never irrigate, clamp or aspirate without order Clamp 1 to 2 hours AC and PC Monitor and document the client’s response to food

Report sudden increases in drainage or amountsexceeding 1000ml/day

Keep drainage bag below level of GB Inspect surrounding skin Maintain flow by gravity Never irrigate, clamp or aspirate without order Clamp 1 to 2 hours AC and PC Monitor and document the client’s response to food

Nursing Interventions:Patient Education

Dietary counseling: Low fat diet Weight reduction Fat-soluble vitamins and bile salts to enhance

absorptions and aid digestion Avoid gas-forming foods Smaller more frequent meals Activity precautions 4-6 weeks Care of T-tube

Dietary counseling: Low fat diet Weight reduction Fat-soluble vitamins and bile salts to enhance

absorptions and aid digestion Avoid gas-forming foods Smaller more frequent meals Activity precautions 4-6 weeks Care of T-tube

References Brunner, L. S., Suddarth, D. S., & Smeltzer, S. C.

(2008). Brunner & Suddarth's textbook of medical-surgical nursing (12th ed.). Philadelphia: LippincottWilliams & Wilkins.

Porth, MC. (6th ED). Pathophysiology. (2002).Philadelphia. USA. Lippincott Willams& Willkins,

A Wolters Kluwer Company

McPhee, J. S., & Papadakis, A. M. (2011). CurrentMedical Diagnosis and Treatment.(50th ED). Chicago. USA: Mc Graw Hill

Brunner, L. S., Suddarth, D. S., & Smeltzer, S. C.(2008). Brunner & Suddarth's textbook of medical-surgical nursing (12th ed.). Philadelphia: LippincottWilliams & Wilkins.

Porth, MC. (6th ED). Pathophysiology. (2002).Philadelphia. USA. Lippincott Willams& Willkins,

A Wolters Kluwer Company

McPhee, J. S., & Papadakis, A. M. (2011). CurrentMedical Diagnosis and Treatment.(50th ED). Chicago. USA: Mc Graw Hill