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CHOLECYSTECTOMY

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Patients Profile
Name: Age: Sex: Civil

Balansag, Nicolas

46 years old Male Status: Married Roman Catholic of Admission: March 5, 2012 No.: 424

Religion: Date

Room

Complaints: Diagnosis:

right upper quadrant pain, general abdominal pain for 1 month Acute Calculous Cholecystitis 4/23/12

Case Abstract

Mr. Balansag is residing at Dona Rita Village 1C Compound, Muntinlupa City with her wife and their 2 daughters. Patient is working as a mechanic at Don Bosco School. Patient is an occasional alcoholic drinker, a slight smoker which consumes around 3 sticks per day.He has no known allergy to food and drugs. Patient is known to be hypertensive at the age of 40. His
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Patient complains of general abdominal pain for 1 month now and that he hasnt been able to sleep well because of the pain felt in his right upper quadrant. He seek consult to Dr. Macadagdag thus advised to be admitted to Medical Centre of Muntinlupa.

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Introduction

Cholecystectomy is the surgical removal of the gallbladder. Despite the development of non-surgical techniques, it is the most common method for treating symptomatic gallstones, although there are other reasons for having this surgery done. Each year more than 500,000 Americans have gallbladder surgery. Surgery options include the standard procedure, called laparoscopic cholecystectomy, and an older moreinvasive procedure, called open cholecystectomy. A cholecystectomy is performed when attempts to treat gallstones with ultrasound to shatter the stones or 4/23/12 medications to

 Gallbladder

disease is cured by removal of the gallbladder in a procedure referred to as a cholecystectomythe most common surgical procedure performed on the biliary tract. A cholecystectomy is performed to relieve the gastrointestinal distress common in patients with acute or chronic cholecystitis (with or without gallstones); it also removes a source of recurrent sepsis. Persistent infection in the biliary tract may 4/23/12

Open cholecystectomy is a surgery in which the abdomen is opened to permit cholecystectomy -- removal of the gallbladder. This operation has been employed for over 100 years and is a safe and effective method for treating symptomatic gallstones,ones that are causing significant symptoms. At surgery, direct visualization and palpation of the gallbladder, bile duct, cystic duct, and blood vessels allow safe and accurate dissection and removal of the gallbladder. Intra-operative cholangiography has been variably used as an adjunct to this operation. The rate of common bile duct exploration for choledocholithiasis (gallstones in the bile duct) varies from 3% in series of patients having elective operations to 4/23/12 21% in series that include all patients. Major

Open Cholecystectomy

In open gallbladder surgery (cholecystectomy), the surgeon removes the gallbladder through a single, large incision in the abdomen. You will need general anesthesia, and the surgery lasts 1 to 2 hours. The surgeon will make the incision either under the border of the right rib cage or in the middle of the upper part of the abdomen (between the belly button and the end of the breastbone).
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Definition of the Disease

Cholelithiasis is a condition in which gallstones, lodge in the neck of the gallbladder or in the cystic duct, interfering with or totally obstruction normal bile flow from the gallbladder to the duodenum. Many factors, some of which aren't well understood, contribute to the formation of gallstones. First is too much cholesterol.Normally, bile contains enough bile salts and lecithin, a fatty compound to dissolve the cholesterol excreted by your liver. But if bile contains more cholesterol than can be dissolved, the cholesterol may form into crystals and eventually into stones. Cholesterolin bile has 4/23/12

If the gallbladder doesn't empty completely or often enough, bile may become too concentrated and contribute to the formation of gallstones. This may occur during pregnancy. No matter what their size, shape or number, gallstones generally fall into one of two categories. First is cholesterol gallstones. These gallstones, often yellow in color, are composed mainly of undissolved cholesterol, although they can also have other components, such as calcium and bilirubin, the residue from the breakdown of red blood cells. About 80 percent of gallstones are cholesterol stones.Second is pigment gallstones. These small, dark brown or black stones form when yourbile contains too much bilirubin. It's not always clear what causes them. They tend 4/23/12

Cholecystitis

Cholecystitis is inflammation of the gallbladder, usually resulting from a gallstone blocking the cystic duct.

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Complications
Pain Peritonitis Pancreatitis Cholecystitis Cholangitis Pancreatitis Nausea

and Vomiting extrahepatic

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Cholestasis, Bile

Stricture

Signs and Symptoms

Cholecystitis usually presents as a pain in the right upper quadrant. This is usually a constant, severe pain. The pain may be felt to 'refer' to the right flank or right scapular region at first. This may also present with the above mentioned pain after eating greasy or fatty foods such as pastries, pies and fried foods. This is usually accompanied by a low 4/23/12

 More

severe symptoms such as high fever, shock and jaundice indicate the development of complications such as abscess formation, perforation or ascending cholangitis. Another complication, gallstone ileus, occurs if the gallbladder perforates and forms a fistula with the nearby small bowel, leading to symptoms of intestinal obstruction. cholecystitis manifests with 4/23/12 non-specific symptoms such as

Chronic

Anatomy Involve DIGESTIVE SYSTEM

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Anatomy of the Main Organ Involve

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GALL BLADDER

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Functions of GALL BLADDER

v

The function of the gallbladder is to store bile and concentrate. Bile is a digestive liquid continually secreted by the liver. The bile emulsifies fats and neutralizes acids in partly digested food. A muscular valve in the common bile duct opens, and the bile flows from the gallbladder into the cystic duct, along the common bile duct, and 4/23/12

The process of gallstone formation is referred to as cholelithiasis. It is generally a slow process, and usually causes no pain or other symptoms. The majority of gallstones are either the cholesterol or mixed type. Gallstones can range in size from a few millimeters to several centimeters in diameter. Most gallstones are formed from cholesterol. Pigment stones, are also very common, they are formed from a brown-colored substance called calcium billirubinate. Patients can have a mixture of the two gallstones type. Cholesterol stones. Although cholesterol makes up only 5% of bile, about of the gallstones. Found in 4/23/12 the US population are formed from cholesterol.

Brief review of Gall stone formation

Cholesterol is not very soluble, so in order to remain suspended in fluid it must be transported within clusters of bile salts called micelles. If there is an imbalance between these bile salts and cholesterol, then the bile fluid turns to sludge. This thckened fluid consists of a mucus gel containing cholesterol and calcium billirubinate If the imbalance worsens, cholesterol crystal form ( a condition called supersaturation), which can eventually form galstones

Supersaturation and cholelithiasis can occur as a result of various abormalities, although the cause is not entirely clear. There are many events that may promote cholelithiasis
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The gallbladder may not be able to empty normally, so bile becomes stagnant The cells lining the gallbladder may not be able to efficiently absorb cholesterol and fat from bile There are high levels of billirubin. Billirubin is a substance normally absorb cholesterol and fat from bile There are high levels of billirubin. Billirubin is a substance normally formed by the breakdown of hemoglobin in the blood. It is removed from the body in bile. Some experts believe billirubinmay play an important role in formation of cholesterol gallstones

Pigment stones. Pigment stones are composed of 4/23/12 calcium billirubinate, or calcified billirubin. Pigment

Diagnostic and Laboratory Tests

Ultrasonography-Gallstones are suspected in patients with biliary colic. Abdominal ultrasonography is the method of choice for detecting gallbladder stones; sensitivity and specificity are 95%. Ultrasonography also accurately detects sludge. CT SCAN MRI (Magnetic Resonance Imaging ) Oral cholecystography Hepatobiliary Nuclear Scan Endoscopic ultrasonography accurately detects small gallstones (<3 mm) and may be needed if
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IMAGES of GALL STONES

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Diagnostic/ Lab test

gallstones and biliary sludge are often detected incidentally when imaging, usually ultrasonography, is done for other reasons. 10 to 15% of gallstones are calcified and visible on plain x-rays. conjugated Bilirubin Alkaline Phosphatase Serum Amylase Lipase
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Asymptomatic

About

Elevated Elevated Elevated Elevated

Diagnostic/ Lab test

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Pathophysiolo gy

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Drug Study

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Nursing Care Plan: Ineffective Breathing Assessment Nursing Diagnosis Planning Interventions Rationale Evaluation Pattern S: Maximizes Short-term: Ineffectivepattern Short-term: of nursing administer O: The patient breathing After 1 hour supplemental available After 1 hour of
1. 1.

may manifest: >tachypnea >reluctance to cough >holding breath > DOB

r/t to pain

interventions, the patient will demonstrate improved breathing pattern. 2. Long-term: After 4 hours of nursing intervention 3. the patient will establish effective breathing pattern 4.

5.

oxygen via nasal cannula as ordered administer pain medications as ordered monitor vital 2. signs especially respiratory rate encourage/assis t with deepbreathing 3. exercises and pursed-lip 4. breathing as appropriate check for restlessness and changes in 5. mental status

oxygen, especially while ventilation is reduced because pain to treat underlying cause of respiratory problem for baseline data promotes maximal ventilation and oxygenation may indicate hypoxia

nursing interventions, the patient shall have demonstrated improved breathing pattern. Long-term: After 4 hours of nursing interventions, the patient shall have established an effective breathing pattern

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Nursing Care Plan: Acute Pain Assessment Diagnosis Planning

S: patient may verbalize: > unrelieved pain O: patient may manifest: > (+) facial grimaces >appears irritable, restlessness >guarded or protective behavior >inability to sleep > pain on the abdominal area Acute pain related to operation performed Short-term: 1. After 1-2 hours of nursing interventions, 2. the patient will demonstrate behaviors to relieve 3. pain Long-term: After 4 hours of nursing interventions, the patient will report pain is controlled. 4.

5.

Interventions Establish 1. rapport Monitor and record vital signs 2. assess the severity, 3. frequency, and characteristic of pain administer medication as ordered provide nonpharmacologi 4. cal intervention 5. such as touch and frequent changing of position

Rationale Evaluation To gain Short-term: patients After 1-2 hours of trust and nursing cooperation interventions, the for baseline patient shall data have pain is a demonstrated subjective behaviors to data, relieve pain therefore it Long-term: should be After 4 hours of reported and nursing to determine interventions, the patients patient shall level of pain have reported to minimize/ pain is relieve pain controlled. to provide comfort

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Nursing Care Plan: Activity Assessment Nursing Intolerance Diagnosis Planning Interventions
S: O: The patient may manifest: >tachypnea >reluctance to cough >holding breath > DOB

Rationale

Evaluation Short-term: After 1 hour of nursing interventions, the patient shall have demonstrated improved breathing pattern. Long-term: After 4 hours of nursing interventions, the patient shall have established an effective breathing pattern

Ineffective Short-term: administer Maximizes breathing pattern supplemental available oxygen, r/t to pain After 1 hour of oxygen via nasal especially while nursing cannula as ventilation is interventions, the ordered reduced because patient will pain demonstrate improved to treat breathing pattern. underlying cause administer pain of respiratory medications as problem Long-term: ordered for baseline data After 4 hours of nursing intervention the monitor vital signs promotes patient will especially maximal establish effective respiratory rate ventilation and breathing pattern oxygenation encourage/assist with deep breathing may indicate exercises and hypoxia pursed-lip breathing as appropriate check for restlessness and changes in mental status

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Nursing Diagnosis

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Acute pain and discomfort related to surgical incision nutrition less than body requirements related to inadequate bile secretion for constipation related to effects of surgery for infection related skin integrity related to disruption of first line of defense intolerance
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Imbalanced

Risk Risk

Impaired Activity

Nursing Interventions

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Relieving Pain
The

location of the subcostal incision in Open Cholecystectomy surgery diseases likely to cause the patient to avoid turning and moving, to splint the affected site, and to take shallow breaths to prevent pain. Because full exacerbation of the lings and gradually increased activity are necessary to prevent postoperative complications, the nurse should administer analgesic agents as prescribed to relieve pain and promote well-being. 4/23/12

Improving respiratory status

Patients undergoing biliary tract surgery are prone to pulmonary complications, as areall abdominal incision. Thus, the nurse remind patient to take deep breaths and coughevery hour to expand the lungs fully and prevent atelectasis.
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The nurse encourages the patient to eat a diet low in fats and high in carbohydrates and proteins especially after surgery. At the time of hospital discharge, these are usually no special dietary instructions other than to maintain a nutritious diet and avoid excessive fats. Fat restriction usually is lifted in 4-6 weeks when the biliary ducts dilate to accommodate the volume
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Improving Nutritional Status

Promote Skin and Biliary Drainage

patient who have undergone cholecystectomy, the drainage tubes must be connected immediately to a drainage receptacle. The nurse fasten tubing to the dressing, with enough leeway for the patient to move without dislodging.
In

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Monitoring and Managing Potential Complications

Bleeding

may occur as a result of inadvertent puncture or nicking of major bloodvessel. Postoperatively, the nurse closely monitors vital signs and inspects the surgicalincision and drains, if in place, for evidence of bleeding.
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