Cholelithiasis

Calculi, or gallstones, usually form in the gallbladder from the solid constituents of bile Clinical Manifestation: Epigastric distress, such as fullness, abdominal distention, and vague pain in the right upper quadrant of the abdomen, may occur. This distress may follow a meal rich in fried or fatty foods. Biliary colic with excruciating upper right abdominal pain that radiates to the back or right shoulder, is usually associated with nausea and vomiting, and is noticeable several hours after a heavy meal. Jaundice Dark Urine Color Putty or grey feces

Pathophysiology:
There are two major types of gallstones: those composed predominantly of pigment and those composed primarily of cholesterol. Pigment stones probably form when unconjugated pigments in the bile precipitate to form stones. The risk of developing such stones is increased in patients with cirrhosis, hemolysis, and infections of the biliary tract. Pigment tones cannot be dissolved and must be removed surgically. Cholesterol, a normal constituent of bile, is insoluble in water. Its solubility depends on bile acids and lecithin (phospholipids) in bile. In gallstone-prone patients, there is decreased bile acid synthesis and increased cholesterol synthesis in the liver, resulting in bile supersaturated with cholesterol, which precipitates out of the bile to form stones. The cholesterol-saturated bile predisposes to the formation of gallstones and acts as an irritant, producing inflammatory changes in the gallbladder.

Diagnostic Procedures:

Nursing Responsibilities: Cholescystectomy Preoperative Instruct the patient about the need to avoid smoking to enhance pulmonary recovery postoperatively and to avoid respiratory complications.
NPO post Midnight

Instruct the patient to avoid the use of aspirin and other agents (over-the-counter medications and herbal remedies) that can alter coagulation and other biochemical processes. Assessment should focus on the patients respiratory status. If a traditional surgical approach is planned, the high abdominal incision required during surgery may interfere with full respiratory excursion. The note history of smoking, previous respiratory problems, shallow respirations, a persistent or ineffective cough, and the presence of adventitious breath sounds. Nutritional status is evaluated through a dietary history and general examination performed at the time of preadmission testing. The nurse also reviews previously obtained laboratory results to obtain information about the patients nutritional status. Postoperative
Place the patient in the low Fowlers position. Intravenous fluids may be given as ordered Nasogastric suction (a nasogastric tube was probably inserted immediately before surgery for a nonlaparoscopic procedure) may be instituted to relieve abdominal distention as Ordered. Water and other fluids are given in about 24 hours Soft diet is started when bowel sounds return. Tell patient to avoid turning and moving, to splint the affected site, and to take shallow breaths to prevent pain Reminds patients to take deep breaths and cough every hour to expand the lungs fully and prevent atelectasis. Fasten tubing to the dressings or to the patients gown, with enough leeway for the patient to move without dislodging or kinking it. Because jaundice may result, the nurse should be particularly observant of the color of the sclerae. The nurse should also note and report right upper quadrant abdominalpain, nausea and vomiting, bile drainage around any drainage tube, clay-colored stools, and a change in vital signs. Closely monitor vital signs and inspects the surgical incisions and drains, if in place, for evidence of bleeding. Periodically assess the patient for increased tenderness and rigidity of the abdomen. Assess the patient for loss of appetite, vomiting, pain, distention of the abdomen, and temperature elevation. These may indicate infection or disruption of the gastrointestinal tract and should be reported to the surgeon promptly. Encourage the patient to eat a diet low in fats and high in carbohydrates and proteins immediately after surgery.

Appendicitis
Inflammation of the Appendix due to the obstruction of fecalith.

Clinical Manifestation:
Vague epigastric or periumbilical pain progresses to right lower quadrant pain low-grade fever Nausea and vomiting. Loss of appetite.

Pathophysiology:
The appendix becomes inflamed and edematous as a result of either becoming kinked or occluded by a fecalith (ie, hardened mass of stool), tumor, or foreign body. The inflammatory process increases intraluminal pressure, initiating a progressively severe, generalized or upper abdominal pain that becomes localized in the right lower quadrant of the abdomen within a few hours. Eventually, the inflamed appendix fills with pus.

Diagnostic Procedures:
A complete physical examination X-ray findings. Complete blood cell count demonstrates an elevated white blood cell count. Abdominal x-ray films, ultrasound studies, and CT scans may reveal a right lower quadrant density or localized distention of the bowel.

Nursing Responsibilities: Appendectomy Preoperative

intravenous infusion to replace fluid loss and promote adequate renal function NPO post Midnight Antibiotic therapy to prevent infection as prescribed. If there is evidence or likelihood of paralytic ileus, a nasogastric tube is inserted. Enema is not administered because it can lead to perforation. Avoid: Ambulation, Heat application, Laxative Pain Medications is contraindicated as it may mask if the appendix has ruptured Place the patient in a semi-Fowler position. This position reduces the tension on the incision and abdominal organs, helping to reduce pain. An opioid, usually morphine sulfate, is prescribed to relieve pain. When tolerated oral fluids are administered. Any patient who was dehydrated before surgery receives intravenous fluids. Food is provided as desired and tolerated on the day of surgery.

Postoperative

Large Bowel Obstruction: Hernia

Protrusion of part of an Intestine through the wall of the cavity that normally contains it

Clinical Manifestation:
Crampy pain that is wavelike and colicky. Patient may pass blood and mucus, but no fecal matter and no flatus. Vomiting occurs.

Pathophysiology:
Intestinal contents, fluid, and gas accumulate above the intestinal obstruction. The abdominal distention and retention of fluid reduce the absorption of fluids and stimulate more gastric secretion. With increasing distention, pressure within the intestinal lumen increases, causing a decrease in venous and arteriolar capillary pressure. This causes edema, congestion, necrosis, and eventual rupture or perforation of the intestinal wall, with resultant peritonitis.

Diagnostic Procedures:
Abdominal x-ray studies show abnormal quantities of gas, fluid, or both in the bowel. Laboratory studies (ie, electrolyte studies and a complete blood cell count) reveal a picture of dehydration, loss of plasma volume, and possible infection.

Nursing Responsibilities: Herniorraphy Preoperative

intravenous infusion to replace fluid loss and promote adequate renal function NPO post Midnight Antibiotic therapy to prevent infection as prescribed. If there is evidence or likelihood of paralytic ileus, a nasogastric tube is inserted. Enema is not administered because it can lead to perforation. Place the patient in a semi-Fowler position. This position reduces the tension on the incision and abdominal organs, helping to reduce pain. Assess for signs of bleeding Maintain hygienic practices An opioid, usually morphine sulfate, is prescribed to relieve pain. When tolerated oral fluids are administered. Any patient who was dehydrated before surgery receives intravenous fluids. Food is provided as desired and tolerated on the day of surgery.

Postoperative

Gastric Cancer
Uncontrolled proliferation of abnormal cells in the stomach, Usually Adenocarcinoma

Clinical Manifestation:
In the early stages of gastric cancer, symptoms may be absent. Early symptoms are seldom definitive because most gastric tumors begin on the lesser curvature, where they cause little disturbance of gastric functions. Some studies show that early symptoms o Pain relieved with antacids, resemble those of benign ulcers. Symptoms of progressive disease may include o Anorexia, o Dyspepsia (indigestion), o Weight loss, o Abdominal pain, o Constipation, o Anemia, o Nausea and vomiting.

Pathophysiology:
Diet appears to be a significant factor. A diet high in smoked foods and low in fruits and vegetables may increase the risk of gastric cancer. Other factors related to the incidence of gastric cancer include chronic inflammation of the stomach, pernicious anemia, achlorhydria, gastric ulcers, H. pylori infection, and genetics. The tumor infiltrates the surrounding mucosa, penetrating the wall of the stomach and adjacent organs and structures. The liver, pancreas, esophagus, and duodenum are often affected at the time of diagnosis. Metastasis through lymph to the peritoneal cavity occurs later in the disease.

Diagnostic Procedures:
Endoscopy for biopsy Barium x-ray examination of the upper GI tract may also be performed. Because metastasis often occurs before warning signs develop, A computed tomography (CT) scan, bone scan, and liver scan are valuable in determining the extent of metastasis. A complete x-ray examination of the GI tract should be performed when any person older than 40 years of age has had indigestion (dyspepsia) of more than 4 weeks duration.

Nursing Responsibilities: Gastric Surgery Preoperative

The major goals for the patient undergoing gastric surgery may include reduced anxiety, increased knowledge and understanding about the surgical procedure and postoperative course, optimal nutrition and management of the complications that can interfere with nutrition, relief of pain, avoidance of hemorrhage and steatorrhea, and enhanced self-care skills at home Patient should assume a low Fowlers position during mealtime, and after the meal the patient should lie down for 20 to 30 minutes. Antispasmodics, as prescribed, also may aid in delaying the emptying of the stomach. Fluid intake with meals is discouraged; instead, fluids may be consumed up to 1 hour before or 1 hour after mealtime. Meals should contain more dry items than liquid items. The patient can eat fat as tolerated but should keep carbohydrate intake low and avoid concentrated sources of carbohydrates. The patient should eat smaller but more frequent meals. Dietary supplements of vitamins and medium-chain triglycerides and injections of vitamin B12 and iron may be prescribed.

Postoperative