Cholelithiasis and Cholecystitis Nursing Care Plan & Management

 Definition

Cholelithiasis
  • Refers to formation of calculi (e.g. gallstones) in the gallbladder.

Cholecystitis

  • Is acute or chronic inflammation of the gallbladder.
    • Acute cholecystits – may be calculous (with gallstones) or acalculous (with gallstones).
    • Chronic cholecystitis – may follow acute cholecystitis, although it often occurs independently. It is usually associated with gallstone formation.
Risk Factors
Cholelithiasis

Results from changes in bile components or bile stasis, associated with:

  • Infection
  • Cirrhosis
  • Pancreatitis
  • Celiac disease
  • Diabetes mellitus
  • Pregnancy
  • Hormonal contraceptive use
Cholecystitis
  • Obstruction of the cystic duct by an impacted gallstone
  • Tissue damage due to trauma, massive burns, or surgery
  • Gram-negative septicemia
  • Multiple blood transfusion
  • Prolonged fasting
  • Hypertension
  • Overuse of opioid analgesics
Pathophysiology
Cholelithiasis

Calculi usually from solid constituents of bile; the three major types are:

  • Cholesterol gallstones – the most common type, thought to form in supersaturated bile
  • Pigment gallstones – formed mainly of unconjugated pigments in bile precipitate
  • Mixed types – with characteristics of pigment and cholesterol stones.

Gallstones can obstruct the cystic duct, causing cholecystitsi, or the common bile duct, which is called choledocholithiasis.

Cholecystitis
  • In acute and chronic cholecystitis, inflammation causes the gallbladder wall to become thickened and edematous and causes the cystic lumen to increase in diameter.
  • If inflammation spreads to the common bile duct, obstruction of bile drainage can lead to jaundice. Other possible complications include: (Empyema i.e. pus-filled gallbladder, perforation, emphysematous cholecystitis)
Assessment/Clinical Manifestations/Signs And Symptoms

Cholelithiasis (up to ½ of persons with gallstones are asymptomatic; however possible clinical manifestations include the following)

  • Episodic (commonly after a high-fat meal), cramping pain in the right upper abdominal quadrant or the epigastrium, possibly radiating to the back near the right scapular tip (i.e. biliary colic)
  • Nausea and vomiting
  • Fat intolerance
  • Fever and leukocystosis
  • Signs and symptoms of jaundice
Acute Cholecystitis
  • Biliary colic
  • Tenderness and rigidity in the right upper quadrant elicited on palpation (i.e. Murphy’s sign)
  • Fever
  • Nausea and vomiting
  • Fat intolerance
  • Signs and symptoms of jaundice
Chronic Cholecystitis
  • Pain, which is less severe than in the acute form
  • Fever, which is less severe than in the acute form
  • Fat intolerance
  • Heartburn
  • Flatulence
Laboratory and diagnostic study findings
Cholelithiasis
  • Biliary ultrasonography (i.e. cholecystosonography) can detect gallstones in most cases.
Cholecystitis
  • White blood cell count reveals leukocytosis
  • Serum alkaline phosphatase is elevated
  • Ultrasonography detects gallstone
  • Endoscopic retrograde cholangiopancreatography may reveal inflamed common bile ducts, gallbladder, and gallstones.
  • Percutaneous transheptic cholangiography can identify gallstones within the bile ducts.
Medical Management
Teach the client about planned treatments.
  • Chenodeoxycholic acid is administered to dissolve gallstones. It is effective in dissolving about 60% of radiolucent gallstones. Pigment gallstones cannot be dissolves and must be excised.
  • Nonsurgical removal, such as lithotripsy or extracorpeal shock wave therapy, may be implemented.
Surgical treatment may be ordered.
Laparoscopic cholecytectomy (usually outpatient surgery) is performed through a small incision made through the abdominal wall in the umbilicus.
  • Assess incision sites for infection. Instruct the client to notify the health care provider if loss of appetite, vomiting, pain, abdominal distention, or fever occur.
  • Advise the client that he will need assistance at home for 2 to 3 days.
Cholecystectomy is removal of the gallbladder after ligation of the cystic duct and artery. Inform the client that a T-tube will be inserted to drain blood; serosanguineous fluids, and bile and that the T-tube must be taped below the incision
Choledochostomy is an incision into the common bile duct for calculi removal.
Cholecystomy is the surgical opening of the gallbladder for removal of stones, bile, or pus, after which a drainage tube is placed.
Nursing Diagnosis
  • Acute pain secondary to biliary obstruction
  • Ineffective coping related to nausea
  • Deficient knowledge related to diagnosis
  • Impaired gas exchange related to high abdominal surgical incision.
  • Impaired skin integrity related to altered biliary drainage after surgical incision.
  • Imbalanced nutrition related to inadequate bile secretion.
Nursing Management
Provide nursing interventions during an acute gallbladder attack.
  • Intervene to relive pain; give prescribed analgesics
  • Promote adequate rest
  • Administer IV fluids, monitor intake and output
  • Monitor nasogastric tube and suctioning
  • Administer antibiotics if prescribed.
Provide adequate nutrition.
  • Assess nutritional status. Encourage a high-protein, high-carbohydrate, low-fat diet.

Nursing Care Plan

Nursing Diagnosis
  • Fluid Volume, risk for deficient
Risk factors may include
  • Excessive losses through gastric suction; vomiting, distension, and gastric hyper­motility
  • Medically restricted intake
  • Altered clotting process