I.

INTRODUCTION

Cholecystitis is an inflammation of the gallbladder wall and nearby abdominal lining. Cholecystitis is
usually caused by a gallstone in the cystic duct, the duct that connects the gallbladder to the hepatic duct.
The presence of gallstones in the gallbladder is called cholelithiasis. Cholelithiasis is the pathologic state of
stones or calculi within the gallbladder lumen.
Gallstones are crystalline structures formed by concretion (hardening) or accretion (adherence of
particles, accumulation) of normal or abnormal bile constituents. According to various theories, there are
four possible explanations for stone formation. First, bile may undergo a change in composition. Second,
gallbladder stasis may lead to bile stasis. Third, infection may predispose a person to stone formation.
Fourth, genetics and demography can affect stone formation.
Risk factors associated with development of gallstones include heredity, Obesity, rapid weight loss,
through diet or surgery, age over 60, Native American or Mexican American racial makeup, female gendergallbladder disease is more common in women than in men. Women with high estrogen levels, as a result
of pregnancy, hormone replacement therapy, or the use of birth control pills, are at particularly high risk for
gallstone formation, Diet-Very low calorie diets, prolonged fasting, and low-fiber/high-cholesterol/highstarch diets all may contribute to gallstone formation.
Sometimes, persons with gallbladder disease have few or no symptoms.

Others, however, will

eventually develop one or more of the following symptoms; (1) Frequent bouts of indigestion, especially
after eating fatty or greasy foods, or certain vegetables such as cabbage, radishes, or pickles, (2) Nausea
and bloating (3) Attacks of sharp pains in the upper right part of the abdomen. This pain occurs when a
gallstone causes a blockage that prevents the gallbladder from emptying (usually by obstructing the cystic
duct). (4) Jaundice (yellowing of the skin) may occur if a gallstone becomes stuck in the common bile duct,
which leads into the intestine blocking the flow of bile from both the gallbladder and the liver. This is a
serious complication and usually requires immediate treatment.
The only treatment that cures gallbladder disease is surgical removal of the gallbladder, called
cholecystectomy. Generally, when stones are present and causing symptoms, or when the gallbladder is
infected and inflamed, removal of the organ is usually necessary. When the gallbladder is removed, the
surgeon may examine the bile ducts, sometimes with X rays, and remove any stones that may be lodged
there. The ducts are not removed so that the liver can continue to secrete bile into the intestine. Most
patients experience no further symptoms after cholecystectomy. However, mild residual symptoms can
occur, which can usually be controlled with a special diet and medication.

ANATOMY AND PHYSIOLOGY

Gallbladder, muscular organ that serves as a reservoir for bile, present in most vertebrates. In humans,
it is a pear-shaped membranous sac on the undersurface of the right lobe of the liver just below the lower
ribs. It is generally about 7.5 cm (about 3 in) long and 2.5 cm (1 in) in diameter at its thickest part; it has a
capacity varying from 1 to 1.5 fluid ounces. The body (corpus) and neck (collum) of the gallbladder extend

backward, upward, and to the left. The wide end (fundus) points downward and forward, sometimes
extending slightly beyond the edge of the liver. Structurally, the gallbladder consists of an outer peritoneal
coat (tunica serosa); a middle coat of fibrous tissue and unstriped muscle (tunica muscularis); and an inner
mucous membrane coat (tunica mucosa).
The function of the gallbladder is to store bile, secreted by the liver and transmitted from that organ via
the cystic and hepatic ducts, until it is needed in the digestive process. The gallbladder, when functioning
normally, empties through the biliary ducts into the duodenum to aid digestion by promoting peristalsis and
absorption, preventing putrefaction, and emulsifying fat. Digestion of fat occurs mainly in the small
intestine, by pancreatic enzymes called lipases. The purpose of bile is to; help the Lipases to Work, by
emulsifying fat into smaller droplets to increase access for the enzymes, Enable intake of fat, including fatsoluble vitamins: Vitamin A, D, E, and K, rid the body of surpluses and metabolic wastes Cholesterol and
Bilirubin.

II.

PATHOPHYSIOLOGY

Risk factor
Heredity
Obesity
Rapid Weight Loss, through diet or surgery
Age Over 60
Female Gender
Diet-Very low calorie diets, prolonged fasting, and low-fiber/high-

Bilecholesterol/high-starch
must become
diets.
supersaturated with
cholesterol and calcium

The solute precipitate

from solution as solid
crystals

Crystals must come

together and fuse to form
stones

Gallstones

Obstruction of the cystic duct and common bile duct

Sharp pain in the right

part of abdomen

Jaundice

Distention of the gall bladder

Venous and
lymphatic drainage
is impaired

Proliferation of
bacteria

Localized cellular
irritation or
infiltration or both
take place

Inflammation of gall bladder

CHOLECYSTITIS

Areas of
ischemia may
occur

III.

DIAGNOSTIC AND LABORATORY PROCEDURE

1. Complete Blood Count (CBC)
This is to determine blood components and the response to inflammatory process and

streptococcal infection.
Date Ordered: February 13, 2006
Date Result In: February 13, 2006
Results:
WBC

10.9 g/l

RBC

5.5 g/l

Lymphocyte

27

Conclusion:
WBC is slightly elevated based on the normal value of 4.3-10 g/l which confirms the
presence of infection.
2.

Fasting Blood Sugar

This is to measure the blood glucose levels.
Date Ordered: February 13, 2006
Date Result In: February 13, 2006
Results:
94.8 mg/dl
Conclusion:
The result is within normal range based on the normal value of < 126 mg/dl.
3.

Creatinine

This is the indicator of the renal function

Date Ordered: February 13, 2006
Date Result In: February 13, 2006
Results:
1.0 mg/dl
Conclusions:
The result is within normal range based on the normal value of 0.60-1.7 mg/dl.
4.

BUN
This is an indicator of renal function and perfusion, dietary intake of CHON and the level

of protein metabolism

Date Ordered: February 13, 2006

Date Result In: February 13, 2006
Results:
10.7 Mg/dl
Conclusions:
The result is within normal range based on the normal value of mg/dl.
5.

Urinalysis
Urinalysis yields a large amount of information about possible disorders of the kidney

and lower urinary tract, and systematic disorders that alter urine composition. Urinalysis data include
color, specific gravity, pH, and the presence of protein, RBCs, WBCs, bacteria, Leukocyte, esterase,
bilirubin,glucose, ketones, casts and crystals.
Date Ordered: February 10, 2006
Date Result In: February 10, 2006
Results:
Color- yellow
Specific Gravity- 0.010
Sugar/ Albumin- negative
Pus cells- 0.1 hpf
Conclusions:
The results are normal but there is a presence of pus cells in the urine which means that
there is also the presence of infection.

IV. Patients Care

a.

Nursing Care Plan

Preoperative NCP
1.

Acute Pain

Assessment
S

O
-

pain scale of
7/10
difficulty in
moving as
manifested by
facial grimaces
(+) pallor
(+) muscle
guarding
RR- 30
BP- 140/90

Nursing Diagnosis
Acute pain related
to inflammation and
distortion of the
gallbladder as
evidenced by verbal
reports of pain.

Scientific
Explanations
Due to the presence
of stones in the
gallbladder it
causes some
obstruction in the
cystic duct which in
turn causes a sharp
acute pain on the
right part of the
abdomen.

Objectives
After 4 hours of
nursing
intervention the
patient will report
relieve of pain.

Nursing
Interventions
1. Observe and
document location,
severity (010
scale),
and character of
pain (e.g., steady,
intermittent,
colicky).
2. Promote bedrest,
allowing patient to
assume position of
comfort.

3. Control
environmental
temperature.
4. Encourage use of
relaxation
techniques, e.g.,
guided
imagery,
visualization, deepbreathing exercises.
Provide
diversional
activities.
5. Make time to
listen to and
maintain frequent
contact with
patient.

Rationale

Evaluation

- Assists in
differentiating cause
of pain, and provides
information about
disease
progression/resolution,
development of
complications, and
effectiveness of
interventions.

Is there a change on
the patients;
a. Pain scale
b. RR
c. BP
d. Reports of
pain
e. Facial
expressions.

- Bedrest in lowFowlers position

reduces intraabdominal
pressure; however,
patient will naturally
assume least
painful position.
- Cool surroundings
aid in minimizing
dermal discomfort.
- Promotes rest,
redirects attention,
may enhance coping.

6. Administer
analgesics as
indicated

- Helpful in alleviating
anxiety and refocusing
attention,
which can relieve
pain.
- Relief of pain
facilitates cooperation
with other
therapeutic
interventions,

2. Fluid Volume deficient

Cues
S

Fluid Volume
Deficient related to
vomiting

O
-

Nursing Diagnosis

(+) pallor
(+) body
weakness
(+)
vomiting
with poor
skin turgor
(+) dry
skin
(+) dry
mouth

Scientific
Explanations
Because of
vomiting excessive
losses through
normal routes occur
thus causes Fluid
Volume Deficient

Objectives
After series of NI
the pt. will maintain
adequate fluid
volume as
evidenced by moist
mucous membranes
and good skin
turgor,

Nursing
Interventions
1. Maintain
accurate record of
I&O, noting output
less than
Intake, increased
urine specific
gravity. Assess
skin/mucous
membranes,
peripheral pulses,
and capillary
refill.
2. Perform frequent
oral hygiene

3. Provide skin and

mouth care

Rationale
- Provides
information about
fluid
status/circulating
volume and
replacement needs.

- Decreases dryness
of oral mucous
membranes; reduces
risk of oral
bleeding.
- Skin and mucous
membranes are dry,
with decreased
elasticity, because
of vasoconstriction
and reduced
intracellular water.
- promotes
hydration.
- Relieves thirst and

Evaluation
Is there still the
presence of;
a. vomiting
b. dry skin
c. dry mouth
d. poor skin
turgor
e. body
weakness

4. Increase fluid
intake
5. Ascertain
patients beverage
preferences, and set
up a 24hr schedule for fluid
intake. Encourage
foods with high
fluid content.

discomfort of dry
mucous membranes
and augments
parenteral
replacement.

- Reduces nausea
and prevents
vomiting.

6. Administer
antiemetics, e.g.,
prochlorperazine
(Compazine) as
ordered by the
physician.
Post-operative NCP
3. Knowledge Deficit
Cues
S
pwede bang
maulit ang sakit
ko as verbalized
by the patient
O
-

Frequently
asking
question about
his condition,
treatment and
diet
With worried
gaze

Nursing
Diagnosis
Deficient
knowledge related
to condition,
prognosis,
treatment, selfcare, and discharge
needs

Scientific
Explanations
There is this
presence of
knowledge deficit
due to some
unfamiliar
information that
causes some
confusion to the
client that needs to
be discussed.

Objectives
After an hour of
nurse-patient
interaction the
patient will
Verbalize
understanding of
disease process,
prognosis, and
potential
complications.

Nursing
Interventions
1. Provide
explanations
of/reasons for test
procedures and
preparation needed.

Rationale

Evaluation

- Information can
decrease anxiety,
thereby reducing
sympathetic
stimulation.

2. Review disease
process/prognosis.
Discuss
hospitalization
and prospective
treatment as
indicated.
Encourage
questions,
expression of
concern.

- Provides knowledge
base from which
patient can make
informed choices.
Effective
communication and
support
at this time can
diminish anxiety and
promote healing.

3. Review drug
regimen, possible

- Gallstones often

a.
b.
c.
d.
e.

Does the
patient
understands
and could
recall all the
teachings
given?
Is there a
significant
changes that
occur on the
patients
knowledge
regarding;
disease
condition
diet
treatment
medication
self-care needs

side effects.
4. Instruct patient to
avoid food/fluids
high in fats (e.g.,
whole milk, ice
cream, butter, fried
foods, nuts, gravies,
pork), gas
producers (e.g.,
cabbage, beans,
onions,
carbonated
beverages), or
gastric irritants
(e.g., spicy
foods, caffeine,
citrus).
5. Suggest patient
limit gum chewing,
sucking on
straw/hard
candy, or smoking.
b.

Drug Study

recur, necessitating
long-term therapy.
- Prevents/limits
recurrence of
gallbladder attacks.

- Promotes gas
formation, which can
increase gastric
distension/discomfort.

Name of Drug

Date
Ordered

GN: H2Bloc
(Pepcidine)
BN: Famotidine

02-13-06

GN: Cefuroxime
BN: Zinacef

02-13-06

Name of Drug

Date
Ordered

Route/
Dosage and
Frequency
PO
20 mg tab at
bedtime

Action

Indication

- Anti-ulcer
- competitively
inhibits action of
histamine on the
H2 at receptor sites
of parietal cells,
decreasing gastric
acid secretion

-for short term

treatment of duodenal
ulcer

- headache,
dizziness,
malaise, dry
mouth

1. Check for doctors order

2. not to be given in patients
hypersensitive to drugs
3. Inform the patient about the possible
side effect of the drug
4. Instruct patient to take drug with
food
5. Advised patient to take drug once
daily usually at bed time
6. Advise patient to report abdominal
pain or blood in stools or is vomiting.

IV
750 mg every
8o prior to OR
(30 to 60
minutes
before)

- anti-infective
- a 2nd generation
cephalosporin that
inhibits cell-wall
synthesis,
promoting osmotic
instability

- perioperative
prophylaxis

- Nausea and
Vomiting

1. Check for doctors order

2. Perform ANST prior to admission
3. Should not be given if positive skin
test
4. Slow IV push
5. Inform the patient about the possible
side effect of the drug
6. Advise patient to report any
discomfort on the IV insertion site

Route/
Dosage and
Frequency

Action

Indication

Adverse
Reaction

Adverse
Reaction

Nursing Consideration

Nursing Consideration

GN:
Clomipramine
HCl
BN: Placil

02-13-06

PO
10 mg tab, at 6
am

- Anti-depressants

- for depression and

chronic pain

- headache,
dizziness,
malaise, dry
mouth

1. Check for doctors order

2. not to be given in patients
hypersensitive to drugs
3. Inform the patient about the possible
side effect of the drug

GN: Gentamicin
Dulfate
BN: Genticin

02-14-06

IV
80 mg amp,
every 80

- Anti-infective
- inhibits protein
synthesis

- endocarditis
prophylaxis for GI or
GU procedure or
surgery

- Nausea and
Vomiting,
headache,
dizziness

N: Ampicillin
BN: Omnipen

02-14-06

IV
1 g amp, every
80

- Anti-infective
- inhibits protein
synthesis

- endocarditis
prophylaxis for GI or
GU procedure or
surgery

- Nausea and
Vomiting,
headache,
dizziness

1. Check for doctors order

2. Perform ANST prior to admission
3. Should not be given if positive skin
test
4. Slow IV push
5. Inform the patient about the possible
side effect of the drug
6. Advise patient to report any
discomfort on the IV insertion site
7. Monitor urine output, specific
gravity, U/A, BUN and creatinine
levels
1. Check for doctors order
2. Perform ANST prior to admission
3. Should not be given if positive skin
test
4. Slow IV push
5. Inform the patient about the possible
side effect of the drug
6. Advise patient to report any
discomfort on the IV insertion site

GN: MgSO4

02-14-06

IV
0.03% 7ml

-anti-convulsant
-replaces

- magnesium
supplementation

- drowsiness,
hypotension

1. Use parenteral magnesium with

extreme caution in patients with

GN: Ketorolac
Tromethamine
BN: Toradol

Name of Drug
GN: Lidocaine HCl

02-14-06

every 120

magnesium and
maintains
magnesium level

IV
30 mg amp,
every 60

- Antiinflammatory
- inhibits
prostaglandin
synthesis

Date Ordered
02-14-06

Route
IV

- short term
management of
moderately severe,
acute pain

Action
Anesthetic drugs

- dizziness,
sedation,
headache,
flatulence,
nausea and
vomiting

Adverse Reaction
-lethargy, hypotension

impaired renal function

2. Test knee jerk and patellar reflexes
before each additional dose
3. check magnesium level after
repeated doses
4. Monitor fluid intake and output
5. Monitor renal function
1. Check for doctors order
2. Perform ANST prior to admission
3. Should not be given if positive skin
test
4. Slow IV push
5. Inform the patient about the possible
side effect of the drug
6. Advise patient to report any
discomfort on the IV insertion site

Nursing Consideration
1. Monitor BP, PR, and RR before and after
giving the medication
2. Monitor patient for toxicity

Anesthetic drug

c. Medical/ Surgical Management

1.

Chest X-ray- this is used to rule out respiratory causes of referred pain.

2.

Intake and Output- I&O measurement provide an other means of assessing fluid balance. This data provide insight into the cause of imbalance such as
decrease fluid intake or increase fluid loss. These measurement are not that accurate as body weight, however, because of relative risk of errors in
recording.

3.

Electrocardiogram- The ECG is an essential tool in evaluating cardiac rhythm. Electrocardiography detects and amplifies the very small electrical
potential changes between different points on the surface of the body as a myocardial cell depolarize and repolarize, causing the heart to contract.

4.

O2 Inhalation- Oxygen therapies are used to provide more oxygen to the body into order to promote healing and health.

5.

Intravenous Rehydration- when the fluid loss is severe or life threatening, intravenous (IV) fluids are used for replacement.

6. ultrasound (Also called sonography.) - a diagnostic imaging technique which uses high-frequency sound waves to create an image of the internal organs.
Ultrasounds are used to view internal organs of the abdomen such as the liver spleen, and kidneys and to assess blood flow through various vessels.

7. hepatobiliary scintigraphy - an imaging technique of the liver, bile ducts, gallbladder, and upper part of the small intestine.
8. cholangiography - x-ray examination of the bile ducts using an intravenous (IV) dye (contrast).
9. percutaneous transhepatic cholangiography (PTC) - a needle is introduced through the skin and into the liver where the dye (contrast) is deposited and
the bile duct structures can be viewed by x-ray.

10. endoscopic retrograde cholangiopancreatography (ERCP) - a procedure that allows the physician to diagnose and treat problems in the liver, gallbladder,
bile ducts, and pancreas. The procedure combines x-ray and the use of an endoscope. A long, flexible, lighted tube. The scope is guided through the
patient's mouth and throat, then through the esophagus, stomach, and duodenum. The physician can examine the inside of these organs and detect any
abnormalities. A tube is then passed through the scope, and a dye is injected which will allow the internal organs to appear on an x-ray.

11. computed tomography scan (CT or CAT scan) - a diagnostic imaging procedure using a combination of x-rays and computer technology to produce
cross-sectional images (often called slices), both horizontally and vertically, of the body. A CT scan shows detailed images of any part of the body,
including the bones, muscles, fat, and organs. CT scans are more detailed than general x-rays.
12. Cholecystectomy- removal of the gallbladder. This procedure may be performed to treat chronic or acute cholecystitis, with or without cholelithiasis, to
remove a malignancy or to remove polyps.
13. Cholecystotomy- the establishment of an opening into the gallbladder to allow drainage of the organ and removal of stones. A tube is then placed in the
gallbladder to established external drainage. This is performed when the patient cannot tolerate cholecystectomy.
14. Choledochoscopy- the insertion of a choledoscope into the common bile duct in order to directly visualize stones and facilitate their extraction.