Cholesterol is the major component of most gallstones in North America, leading to speculation that the high-fat diet common to many North Americans is the explanation for their increased frequency. Supporting theories that point to a high-fat diet note that acute attacks of cholelithiasis may be precipitated by fasting and sudden weight loss.
Nursing care plan assessment and examination
Cholecystitis often begins as a mild intolerance to fatty food. The patient experiences discomfort after a meal, sometimes with nausea and vomiting, flatulence, and an elevated temperature. Over a period of several months or even years, symptoms progressively become more severe. Ask the patient about the pattern of attacks; some mistake severe gallbladder attacks for a heart attack until they recall similar, less severe episodes that have preceded it. 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.
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 and requires no physical examination. It is 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.
The patient with an acute attack of cholelithiasis may be in extreme pain and very upset. The experience may be complicated by guilt if the patient has been advised by the physician in the past to cut down on fatty foods and lose weight. The attack may also be very frightening if it is confused with a heart attack.
Nursing care plan primary nursing diagnosis: Pain (acute) related to obstruction and inflammation.
Nursing care plan intervention and treatment
Medical management may include oral bile acid therapy. However, given the effectiveness of laparotic cholecystectomy, the only patients who will receive medical dissolution, except those nonobese patients with very small cholesterol gallstones and a functioning gallbladder.
There are several surgical or procedural treatment options. The one seen most commonly today is a laparoscopic cholecystectomy, which is performed early (within 48 hours of acute onset of symptoms) in the course of the disease when there is minimum inflammation at the base of the gallbladder. The procedure is performed with the abdomen distended by an injection of carbon dioxide, which lifts the abdominal wall away from the viscera and prevents injury to the peritoneum and other organs. A laparoscopic cholecystectomy is done either as an outpatient procedure or with less than 24 hours of hospitalization. After the surgery, the patient may complain of pain from the presence of residual carbon dioxide in the abdomen.
The traditional open cholecystectomy is performed on patients with large stones, as well as with other abnormalities that need to be explored at the time of surgery. This procedure is particularly appropriate up to 72 hours after onset of acute cholecystitis. Timing of the operation is controversial. Early cholecystectomy has the advantage of resolving the acute condition early in its course. Delayed cholecystectomy can be performed after the patient recovers from initial symptoms and acute inflammation have subsided, generally 2 to 3 months after the acute event. Extracorporeal shock wave lithotripsy similar to the type used to dissolve renal calculi is now also used for small stones. For those patients who are not good surgical candidates, both methods have the advantage of being noninvasive. However, they have the disadvantage of leaving in place a gallbladder that is diseased, with the same propensity to form stones as before treatment.
During an acute attack, remain with the patient to provide comfort, to monitor the result of interventions, and to allay anxiety. Explain all procedures in short and simple terms. Provide explanations to the family and significant others. If the patient requires surgery, the nurse’s first priority is the maintenance of airway, breathing, and circulation. Although most patients return from surgery or a procedure breathing on their own, if stridor or airway obstruction occurs, create airway patency with an oral or nasal airway and notify the surgeon immediately. If the patient’s breathing is inadequate, maintain breathing with a manual resuscitator bag until the surgeon makes a further evaluation. The high incision makes deep breathing painful, leading to shallow respirations and impaired gas exchange. Splinting the incision while encouraging the patient to cough and breathe deeply help both pain and gas exchange. Elevate the head of the bed to reduce pressure on the diaphragm and abdomen. Patients not undergoing surgery or a procedure need a thorough education. Explain the disease process, the possible complications, and all medications. Teach the patient to avoid high-fat foods, dairy products, and, if the patient is bothered by flatulence, gas-forming foods.
Nursing care plan discharge and home health care guidelines
After a laparoscopic cholecystectomy, provide discharge instructions to a family member or another responsible adult, as well as to the patient, because the patient goes home within 24 hours after surgery. Explain the possibility of abdominal and shoulder pain because of the instillation of carbon dioxide to prevent anxiety about a heart attack if the pain occurs. Teach the patient to avoid submerging the abdomen in the bathtub for the first 48 hours, to take the prescribed antibiotics to provide further assurance against infection, and to watch the incisions for signs of infection. Following a 3- to 5-day hospital stay for an open cholecystectomy, instruct the patient on the care of the abdomen wound, including changing the dressing and protection of any drains.
Reinforce pain control and deep-breathing exercises until the incision is completely healed. The patient may need instruction on control of elimination after this surgery. The continued use of opiate-type analgesics for 7 to 10 days may necessitate the use of laxatives or suppositories, which are generally prescribed by the physician before discharge. Explain that gradual resumption of both a normal diet and activity aid normal elimination. Instruct the patient to report to the physician if any new symptoms occur, such as the appearance of jaundice accompanied by pain, chills and fever, dark urine, or light-colored stools. Usually, the patient has no complications and is able to resume normal activity within a few weeks. Instruct the patient who has been treated nonsurgically with bile salts or extracorporeal shock wave lithotripsy about a low-fat diet to avoid recurrence of gallstones.