CHOLECYSTITIS

( Inflammation of the Gall Bladder)

IN TRODUCTION
CHOLECYSTITIS
• Very rarely, even in the absence of
cholelithiasis, gall bladder can become
inflamed and infected. This is known as acute
acalculous cholecystitis, where the pain lasts
longer and is severe
• Typically, people have abdominal pain that
lasts more than 6 hours, fever, and nausea.
• Ultrasonography can usually detect signs of
gallbladder inflammation.
OBJECTIVES
• To determine the content on the nursing
assessment, diagnosis, planning, Implementation
and evaluation for this specific disease condition

• To know the underlying causes and health history

on the clients medical diagnosis upon admission
 
• To search the medical management as being
ordered based upon the clients diagnostic and
laboratory results
• To compare and contrast the ideal and actual
nursing care management for this specific
disease condition

• Utilize the nursing process as a framework for

care of patients with cholecystitis

• To evaluate the effectiveness of the

interventions and detect any progress of the
clients condition.
PATIENT PROFILE
PRESENT MEDICAL
HISTORY
• THREE DAYS PTA: The patient has epigastric pain with a pain scale
of 5/10 accompanied with 2 bouts of vomiting of previously
ingested food.
• ( - fever )
• No medication taken; no consultation.
• ONE DAY PTA: still with above condition. Patient given Tromadol
offered no relief.
• FEW HOURS PTA: persistence of above condition. Consult advised
admission.
• VITAL SIGNS (taken May 15,2010)
• Temperature: 37.1C
• Pulse rate: 120
• Respiratory rate: 19
• Blood Pressure: 140/90
Past medical history
• ( + ) Hypertension highest BP 170/100 (1999)
usual BP 130/80
• (amlodipine 10mg OD)
•
• ( + ) CVA infarct in the left hemisphere (april
23,2010)
• (Citicoline 1g BID)
• (ASA 325mg OD)
• (Simvastatin 20mOD)
• (Combizar 1tab OD)
• (Lexapin 10mg OD ½ cap)
• (Iron OD)
THEORETICAL
FRAMEWORK
Self – Care Deficit Theory of
Nursing

Self
care
R R
Therap
eutic
Self R Self
Care care
Agency deman
ds
Deficit

R R
Nursing
Agency
GORDON’S
FUNCTIONAL
HEALTH PATTERN
Gordon’s Functional Health Pattern

Before Hospitalization During Hospitalization

Health Perception and - Knows the importance - Knowledgeable about her

Health Management of being healthy; condition
Pattern observes proper hygiene;
consults doctor

Nutritional and Metabolic - Eats vegetables; loves -Loss of appetite

Pattern sour foods; loves to drink
softdrinks;

Elimination Pattern - Defacates twice a day; - Uses commode

micturates 8-9 times a
day
Activity-Exercise Pattern - Walking and cleaning - Stays in bed
the house; watching tv is
her past time
Before Hospitalization During Hospitalization

Sleep-Rest Pattern - 6 hours of sleep and 2 - Sleeps more often than the
hours of nap in the usual sleep pattern
afternoon

Cognitive-Perceptual Pattern - Hearing is clear; has - Hearing is clear; has

difficulty in writing difficulty in writing

Self Perception and Self - Visualizes herself as a - Tries to be more stronger

Concept Pattern strong person; focuses on for her family and herself
her family

Religion - Roman Catholic; goes to - Never forgets to pray the

church and prays the rosary rosary

Vices - Doesn’t have any vices - Doesn’t have any vices

Sexual Pattern - Believed in family planning Decreased interest in sexual

activity
PHYSICAL
ASSESSMENT
PHYSICAL ASSESSMENT
Physical assessment done:
May 19, 2010

GENERAL
HEENT Unremarkable
RESPIRATORY Unremarkable
CARDIOVASCULAR Unremarkable
GASTRO-INTESTINAL Remarkable
GENITO-URINARY Unremarkable
ENDOCRINE Unremarkable
MUSCULO-SKELETAL Unremarkable
PSYCHIATRIC Remarkable
ANATOMY AND
PHYSIOLOGY
PATHOPHYSIOLOGY
CHOLECYSTITIS WITH
CHOLELITHIASIS
Cause: UNKNOWN  PREDISPOSING
FACTORS: Female
Hemolysis (5 F’s)
Forty

Fertile:
Hemoglobin Decrease bile acid synthesis (multigravida; use
in the liver of OCP)

Bilirubin
Increase cholesterol
synthesis in the liver Fair (Caucasian)

CA bilirubinate/ Calcified bilirubin

Bile supersaturated with Fat (obese)
cholesterol

Gallstones Bile stone

CHOLELITHIASIS Bile flow Irritation of the gall bladder

obstrn (inflammation) CHOLECYSTITIS
BILE STASIS
> Biliary colic
> N&V >RUQ pain that may
> Murphy’s sign radiate to midsternal/
LEGEND:
> Jaundice right shoulder
Predisposing factors
>N&V
Pigmented gallstones
>Fever
Cholesterol gallstones
>Leukocytosis
S/S of Cholelithiasis
S/S of Cholecystitis
Cause: UNKNOWN  PREDISPOSING
Female 47
FACTORS:
(5 F’s)
Forty
RBC:3.29 (4.2-5.4 X10 /L) 2 children
Slightly anisocytosis and slightly
Fertile:
poikilocytosis Hemolysis (multigravida; use
of OCP)

Hgb: 97 (117-157 g/L)

> Biliary colic
Hemoglobin > N&V
CA bilirubinate/ Calcified bilirubin

Direct Bilirubin: 9.48umol/L

Indirect BIlirubin:18.51umol/L Bilirubin

CHOLELITHIASIS
>RUQ pain that may CHOLECYSTITIS Gallstones
radiate to
midsternal/ right
shoulder
Irritation of the gall bladder Bile obstruction BILE
>N&V LEGEND: (inflammation) STASIS
>Leukocytosis - 39 Predisposing factors
Pigmented gallstones
Cholesterol gallstones
SGPT: 168 (5-40 U/L)
S/S of Cholelithiasis
SGOT: 233 (0-35 U/L)
S/S of Cholecystitis
LABORATORY
AND DIAGNOSIS
Date Lab/Dx Diagnostic Use Px Result Normal Values Signifi-cance
05-15-2010 FBS 8.60 3.9-6.05 mmol/L Transient hypergly-
cemia
Choles-terol CVA 2.62 3.64-6.50 Hypocholes-
Cholesterol bile stone terolemia (CVA)
SGPT Liver Fxn 168 5-40 U/L Biliary stasis
SGOT Liver Fxn 233 0-35 U/L Biliary stasis
Direct Bilirubin Measure bilirubin from hgb 9.48 0-8.55 umol/L Biliary stasis
breakdown
Indirect Bilirubin Measures bilirubin that has 18.51 8.55-17.1 umol/L Biliary stasis
been processed by the liver
Amylase R/O acute inflammation of 31 30-110 U/L
the pancreas
Na Check for electrolyte 120 135-148 mmol/L Hyponatre-mia
imbalance
K Check for electrolyte 2.4 3.5-5.3 mmol/L Hypokale-mia
imbalance
F/A R/O other abdominal Color:
diseases that causes Greenish brown Brown (diet dependent) Bile leakage into the
abdominal pain like Microscopic reading: NOPS feces
rotavirus, amoebiasis etc.
U/A To screen for metabolic and Color: d. yellow Straw/amber
kidney disorders and for CHON: trace Negative Stressed kidney
urinary tract infections Pus: 3-5 0-1/hpf
RBC: 1-2 0-1/hpf
Hyaline cast: 0/lpf
5-7/lpf 0/lpf
Fine granular cast:
1-2/lpf
Date Lab/Dx Diagnostic Use Px Result Normal Values Signifi-cance

5-15-2010 CBC Act as baseline Hgb: 97 117-157 g/L ANEMIA

diagnosis; broad Hct: .27 .37-.47 % INFECTION
screening test to RBC: 3.29 3.80-5.20x10/L Bacteria
check for disorders Remarks: Slghlty 4.5-11 x 10/L
such as anemia, anisocytosis, slighltly .40-.70 %
infection and other poikilocytosis 150-400x 10/L
disorders WBC: 39
Neu: 0.95
Platelet: 440

5-16-2010 CBC Hgb:90

Hct:.26
RBC: 3.27
WBC:25
Neu:0.93
5-17-2010 CBC Hgb: 91 1hr post BT 1u PRBC
Hct:.28 250 cc
RBC:3.31 10-04-1600
WBC: 22
Neu: 0.93
5-18-2010 CBC Hgb: 93 1hr post BT 1u PRBC
Hct:.27 250 cc
RBC:3.39 09-25-1962
WBC: 22.4
Neu: .87
5-19-2010 CBC Hgb: 113
Hct:..33
RBC:4.06
WBC: 21.3
Neu: .88
Date Lab/Dx Diagnostic Use Impression Significance
5-15-2010 Portable CXR (AP CP clearnce Probable Cardiomegaly CVA
view)
Abdominal UTZ Check for bowel  Mild pelvocaliec-tasis/ R kidney Suspected stones
obstruction
Gall bladder and liver Measure the size of the  Minimal fluid collection right Inflammation of the gall
UTZ organ and suggestive sub-hepatic area bladder with stone
diagnosis  Cholecystitis with cholelithiasis formation
and bile sludge formation
 Pericholecystic collection
 Borderline common bile duct size
 Suggestive of diffuse
parenchymal liver diease

Gynecology and fertility Check for reproductive  Anteverted sized uteru with Suggestive of encysted
UTZ system abnormality homogenous myometrium fluid
 Secretory phase-like endometrium
 N ovaries
 Encysted fluid
 (+) fluid in the cul-de-sac
 Remarks: anterior to uterus is an
irregular fluid collection with thin
septations measuring 37x26x34
mm.
Date Lab/Dx Diagnostic Use Px Result Normal Values Signifi-cance

5-15-2010 Potassium Electrolyes Imbalnce; 2.4 3.5-5.3 mmol/L Hypokalemia-

CVA vomiting

5-16-2010 K 2.8 1 hr after K correction

PNSS 85cc + 30 meqs
KCl 3hrs x 1 cycle

5-17-2010 K 3.1
5-18-2010 K 3.5 1 hr after K correction
PNSS 80cc + 40 meqs
KCl 3hrs x 1 cycle

5-19-2010 K 3.6 1 hr after K correction

PNSS 90cc + 20 meqs
KCl 2hrs x 2 cycle

5-20-2010 K 3.9
PRE AND POST
OPERATIVE PLAN
Pre – Operative Care
• On admission to the hospital, an
informed consent form
acknowledging that the patient
understands the procedure, the
risks, and that they will be receiving
anesthesia and possibly other
medications must be signed.
• IV fluid to replace fluid electrolyte
losses due to vomiting.
• DBCT exercises to prevent
respiratory complications.
Post – Operative Care
• Position low /semi – fowler’s
position to promote lung
expansion.
• NGT to prevent gastric distention.
• DBCT exercises to avoid
atelectasis.
• Low fat diet for 2 – 3 months.
• Ambulation after 24 hours post –
operatively.
Surgical
Procedure
Laparoscopic Cholecystectomy
Laparoscopic cholecystectomy is performed
through a small incision or puncture made
through the abdominal wall at the umbilicus. The
fiberoptic scope is inserted through the small
umbilical incision. Several additional punctures or
incisions are made in the abdominal wall to
introduce other surgical instruments into the
operative field. The surgeon visualizes the biliary
system through a laparoscope, the gallbladder is
then removed from the abdominal cavity after
bile and small stones are aspirated.  
DRUG STUDY
5-15-2010
DRUG INDICATION MECHANISM OF CONTRAINDICATION ADVERSE EFFECT NURSING
ACTION RESPONSIBILITIES

Generic: clonidine Management of mild to Stimulates alpha- Contraindicated w/ bradycardia, Monitor blood
hydrochloride moderate adrenergic receptor in hypersensitivity to hypotension, pressure and pulse
Brand: Catapres hypertension. the CNS; w/c results in clonidine or any palpitation, drowsiness, frequently during initial
Classification: decreased sympathetic adhensive layer dry mouth dosage adjustment and
antihypertensive outflow inhibiting components of the periodically throughout
Dosage: cardioacceleration and transdermal system. therapy.
75 pcg/ tab vasoconstriction Instruct patient to take
Route: SL centers. Decreased clonidine @ the same
Frequency: PRN for blood pressure. time each day, even if
BP 160/90 mmHg feeling well.
Inform patient that
clonidine may cause
drowsiness; w/c
usually diminishes w/
continued use.
 If dry mouth occurs,
advise patient to rinse
mouth frequently.
Instruct patient and
family on proper
teaching for blood
pressure monitoring at
least weekly.
5-16-2010
DRUG INDICATION MECHANISM OF CONTRAINDICATION ADVERSE NURSING
ACTION EFFECT RESPONSIBILITIES

Generic: Acute infection w/ Inhibits DNA synthesis Contraindicated with seizures, Monitor neurologic status
metronidazole susceptible anaerobic in specific anaerobes hypersensitivity to dizziness, during and after IV
Brand: Flagyl bacteria. causing cell death. metronidazole. headache, infusion. Inform physician
Classification: Acute intestinal amebicidal action. abdominal pain, if seizure, dizziness or
antibacterial amebiasis. darkening of the headache occur.
antiprotozoal Perioperative, urine, nausea, Inform the patient that his
antibiotic intraoperative, vomiting and urine will be darker than
Dosage: postoperative prophylaxis metallic taste usual.
5 mg/ml infused for patients undergoing Take full course of drug
over 30-60 mins. colorectal surgery. therapy; take the drug with
Route: IV food or milk if GI upset
Frequency: q8 occurs.
Instruct the patient to take
medication exactly as
directed evenly spaced
times between dose, even
if feeling better. Do not
skip doses or doble up
missed doses. If a dose is
missed, take as soon as
remembered if not almost
time for next dose.
Inform patient that
medication may cause an
unpleasant metallic taste.
5-16-2010
DRUG INDICATION MECHANISM OF CONTRAINDICATION ADVERSE NURSING
ACTION EFFECT RESPONSIBILITIES

Generic: Treatment of the following Inhibit bacterial DNA Hypersensitivity. Cross- dizziness, May cause dizziness &
ciprofloxacin bacterial infections: synthesis by inhibiting sensitivity among agents headache, drowsiness. Caution
Brand: Cipro Urinary tract infections DNA gyrase. within class may occur . drowsiness, patient to avoid driving or
Classification: anti including Therapeutic effects: Use cautiously in: Known or diarrhea, other activities requiring
infectives cystitis,gynecologic Death of susceptible suspected CNS disorder; nausea, other activities requiring
Dosage: infections, respiratory tract bacteria. Renal Impairment. vomiting, alertness until response to
40 mg. infections. abdominal pain medication is known.
Route: IV Assess for infection prior
Frequency: qid to & during theraphy.
Instruct patient to notify
health care profesiional if
fever & diarrhea develop,
especially if stool contains
blood, pus, or mucus.
Advise patient not to treat
diarrhea without consulting
health care professional.
If gastric irritation occurs,
ciprofloxacin may be
administered with meals.
5-20-2010
DRUG INDICATION MECHANISM OF CONTRAINDICATION ADVERSE REACTION NURSING
ACTION RESPONSIBILITY

Generic: Relief of allergic Competitively blocks Hypersensitivity drowsiness, dizziness, Monitor

diphenhydramine symptoms caused by the effects of Acute attacks of blurred vision and dry patient
Brand: Hizon histamine release histamine at H1- asthma mouth response; and
diphenhydramine Mild sedation receptor sites; lactation arrange for
injection antipruritic and adjustment of
Classification: sedative effect. dosage to
antihistamine/ sedative lowest
hypnotic possible
Dose: 25 mg effective dose.
Route: IM Inform the
Frequency: 1 dose patient before
administering
that the
medication
may cause
drowsiness,
dizziness and
blurred vision.
Report DOB,
hallucination,
unusual
bleeding and
irregular
heartbeat.
DATE: MAY 20, 2010

DRUGS: Action: Contra-Indication Adverse Nursing responsibilities

Indication Reactions

Generic: Moderate to Binds to opiaite Hypersensitivity Dizziness,  Assess bp, pr, rr bef. And periodically during
Nalbuphine severe pain. receptor in the Patient who are headache , dry administration.
Dose: 5mg Also provide: CNS. Alter the physically on mouth, N/V, (<10min assess for level of sedation)
Frequency:q6 sedetion before perception of or/ opioids and have clammy feeling.  Instruct pt. on how and when to ask for pain
Brand:Nubain surgery, and response to not been medication.
Route: IV supplement to painful stimuli detoxified.  May cause dizziness. Advice pt. to call for
Classification: balance while producing assistance when ambulating until response to
Opioid anesthesia. generalized the med is known.
Analgesic CNS  Advice pt. that freq. mouth rinses, good oral
depression. hygiene, can decrease dry mouth.
5-20-2010
DRUG INDICATION MECHANISM OF CONTRAINDICATION ADVERSE NURSING
ACTION EFFECT RESPONSIBILITIES

Generic: GERD/ maintenance of Binds to an enzyme on Contraindicated with drowsiness, PO: Administer doses
omeprazole healing in erosive gastric parietal cells in hypersensitivity to headache, before meals, preferable in
Brand: omepron esophagitis. the presence of acidic omeprazole. abdominal pain, the morning
Classification: anti Short term treatment of gastric pH, in preventing diarrhea, May cause occasional
ulcer agent active benign gastric the lumen. drowsiness. Caution
Dosage: ulcers. patient to avoid driving or
40 mg other activities requiring
Route: PO alertness until response to
Frequency: OD medication is known.
Assess patient routinely
for epigastric/ abdominal
pain & frank or occult
blood in the stool,emesis.
Advise patient to avoid
alcohol, products containg
aspirin/ NSAIDS & foods
that may cause an
increase in GI irritation.
Advise patient to report
onset of black, tarry stools,
diarrhea; abdominal pain
or persistent headache to
health care professional
promptly.
5-21-2010
DRUG INDICATION MECHANISM OF CONTRAINDICATION ADVERSE NURSING
ACTION REACTION RESPONSIBILITY

Generic: parecoxib Short term treatment Inhibits prostaglandin Contraindicated w/ allergies headache, dizziness, Asses BP, RR, PR
Brand: Dynastat of acute pain and synthesis by selecting to celecoxib, NSAIDs and fatigue, flatulence, before and periodically
Classification: NSAID post-op pain inhibiting cyclo- aspirin abdominal pain during administration.
Dose: 40 mg oxygenase-2. Significant renal impairment Inform the patient that
Route: IV Relieves pain and he will experience
Frequency: 1 dose inflammatory adverse effect such as
dizziness and
drowsiness.
Advise patient that
frequent mouth rinse,
good oral hygiene and
candy can decrease dry
mouth.
NURSING CARE
PLAN
LEGEND:
Profile
Subjective
Objective
Diagnosis
Intervention
Rationale
Evaluation
Pre - Operative Acute pain After 8 hours of nursing
related to intervention the client
“ Ang sakit ng tiyan ko”
inflammation of will be able to
Patient A as verbalized by the
the gallbladder demonstrate use of
41 F patient
relaxation skills and
Dr. Romcilla diversional activities as
indicated, for individual
situation

Accepted Provide
Guarding client’s comfort After 8 hours of
Behavior description measures nursing
protective of pain. touch, intervention the
gestures repositioning, client will be able
and use of hot and to demonstrate
positioning cold packs, use of relaxation
to avoid Encouraged quiet skills and
pain use of environment diversional
relaxation activities as
techniques. indicated, for
(eg. Music) To distract individual
attention and situation
Facial Grimace reduce tension.
Administer
analgesics as LEGEND:
indicated, to Promotes non –
maximum pharmacological Profile
dosage, as pain mngt. Subjective
needed Objective
RUQ Pain Diagnosis
Pain Scale: 5/10 Intervention
BP: 140/90 Rationale
PR:90 Evaluation
DISCHARGE
PLANNING
• M – Medication (geltasine, omeprazole,
ciprofloxacin, catapres, metronidazole)

• E – Exercise

• T – Treatment

• H – Health Teaching

• O – Outpatient

• D – Diet (what and what not to eat)

• S – Spiritual