Care of the Client with Disorders of the Gallbladder ACC RNSG 1247.
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Transcript of Care of the Client with Disorders of the Gallbladder ACC RNSG 1247.
Care of the Client with Care of the Client with Disorders of the Disorders of the
GallbladderGallbladder
ACC RNSG 1247ACC RNSG 1247
Gallbladder DiseaseGallbladder Disease
Two main disorders:Two main disorders: CholecystitisCholecystitis CholelithiasisCholelithiasis
Risk factors for GB diseaseRisk factors for GB disease
Higher in women: Higher in women:
multiparous, over 40, on estrogen therapy multiparous, over 40, on estrogen therapy Sedentary lifestyleSedentary lifestyle Familial tendencyFamilial tendency ObesityObesity
Etiology of CholecystitisEtiology of Cholecystitis
Acute :Acute :
- Calculous: with stone obstruction- Calculous: with stone obstruction
- Acalculous: absence of stones- Acalculous: absence of stones Chronic:Chronic:
- Repeated attacks, long standing - Repeated attacks, long standing
inflammation inflammation
Pathophysiology of CholecystitisPathophysiology of Cholecystitis
Obstruction leads to ischemia of GB mucosa Obstruction leads to ischemia of GB mucosa or wall or wall
Inflammation may follow: GB is edematous Inflammation may follow: GB is edematous during acute attack or distended with bile or during acute attack or distended with bile or puspus
Cystic duct may be occludedCystic duct may be occluded GB becomes scarredGB becomes scarred
Clinical Manifestations of Clinical Manifestations of AcuteAcute vs Chronic Cholecystitisvs Chronic CholecystitisWhich are acute signs; which are chronic?Which are acute signs; which are chronic?
________________ Usually begins with a Usually begins with a
biliary colic attackbiliary colic attack RUQ pain RUQ pain N/VN/V Usually signs of acute Usually signs of acute
inflammationinflammation Possible pus Possible pus
formationformationgangrenousgangrenous
______________ Dull acheDull ache History of fat History of fat
intoleranceintolerance DyspepsiaDyspepsia Increased flatulenceIncreased flatulence
CholelithiasisCholelithiasis
Calculi (stones) in the GBCalculi (stones) in the GB May obstruct the cystic or CBDMay obstruct the cystic or CBD Choledocholithiasis: stones in the CBDCholedocholithiasis: stones in the CBD Types:Types:
Composed primarily of pigmentComposed primarily of pigment Composed primarily of cholesterolComposed primarily of cholesterol
Pathophysiology of CholelithiasisPathophysiology of Cholelithiasis
Develops when the balance that keeps Develops when the balance that keeps cholesterol, bile salts and calcium is altered cholesterol, bile salts and calcium is altered causing precipitation of these substancescausing precipitation of these substances
Conditions affecting balance: infection and Conditions affecting balance: infection and altered metabolism of cholesterolaltered metabolism of cholesterol
Bile in GB and liver become saturated with Bile in GB and liver become saturated with cholesterolcholesterol
Cholesterol vs Pigment StonesCholesterol vs Pigment StonesWhich is which & which is more common?Which is which & which is more common?
____________________________ 4x more prevalent in 4x more prevalent in
womenwomen formation incidence formation incidence
increased in use of oral increased in use of oral
contraceptives, estrogenscontraceptives, estrogens
_____________ made of other bile
components (bile salts, bilirubin, Ca, protein)
undissolvable; requires surgery
increased risk in: cirrhosis, hemolysis, biliary tree infections
Clinical Manifestations of Clinical Manifestations of CholelithiasisCholelithiasis
““Silent cholelithiasis”Silent cholelithiasis” Pain and biliary colicPain and biliary colic Sx RT bile obstructionSx RT bile obstruction
such as jaundice, pruritus,such as jaundice, pruritus,
changes in color of stool changes in color of stool
and urine, vitamin and urine, vitamin
deficiency, bleeding, deficiency, bleeding,
steatorrheasteatorrhea
Diagnostic StudiesDiagnostic Studies History & physical examinationHistory & physical examination Would these laboratory tests show increased or Would these laboratory tests show increased or
decreased levels? decreased levels?
* Liver function tests* Liver function tests
* WBC count* WBC count
* Serum bilirubin* Serum bilirubin
* Serum amylase* Serum amylase
Diagnostic TestsDiagnostic Tests
Abdominal x-raysAbdominal x-rays Ultrasonography – most accurate Ultrasonography – most accurate HIDA scan HIDA scan Endoscopic retrograde Endoscopic retrograde
cholangiopancreatography (ERCP)cholangiopancreatography (ERCP) Percutaneous transhepatic cholangiographyPercutaneous transhepatic cholangiography
Treatment & Nursing CareTreatment & Nursing CareAcute episodes focus on Acute episodes focus on * Pain control – * Pain control – - Morphine- Morphine - Dilaudid (hydromorphone)- Dilaudid (hydromorphone)
- Ketorolac (Toradol- Ketorolac (Toradol) ) - - Demerol (MeperidineDemerol (Meperidine) ) - - NSAIDS, anticholinergicsNSAIDS, anticholinergics
* Infection Control - antibiotics * Infection Control - antibiotics
Treatment & Nursing Care Treatment & Nursing Care continuedcontinued
*Fluid and electrolyte balance*Fluid and electrolyte balance - IV fluid- IV fluid - Antiemetics : - Antiemetics : Metoclopramide (Reglan) Metoclopramide (Reglan) Ondansentron (Zofran)Ondansentron (Zofran) Prochlorperazine (Compazine)Prochlorperazine (Compazine) Gastric Decompression Gastric Decompression – NGT, NPO– NGT, NPO
• *How/what would you monitor to maintain F & E *How/what would you monitor to maintain F & E balance?balance?
Treatment and Nursing CareTreatment and Nursing Care
Once attack is over maintain onOnce attack is over maintain on _____ fat diet _____ fat diet _________ forming foods_________ forming foods Avoid eggs, whole milk products, cheese,Avoid eggs, whole milk products, cheese,
ice cream, fried foods, rich foods, alcoholice cream, fried foods, rich foods, alcohol Reduced _______ diet if obese Reduced _______ diet if obese
Treatment & Nursing Care:Treatment & Nursing Care:Supportive Drug TherapySupportive Drug Therapy
* Fat soluble vitamin replacement: A,D,E,K* Fat soluble vitamin replacement: A,D,E,K
* Bile salts: Ex: Decholin; enhance fat * Bile salts: Ex: Decholin; enhance fat
absorptionabsorption
* Bile acids: Exs: Questran and Cholestid; * Bile acids: Exs: Questran and Cholestid;
bind bile salts and treat pruritus bind bile salts and treat pruritus
Treatment and Nursing Care:Treatment and Nursing Care:Non Surgical Stone Approaches for Non Surgical Stone Approaches for
Stone RemovalStone Removal
* endoscopic sphincterotomy (papillotomy)* endoscopic sphincterotomy (papillotomy) * mechanical lithotripsy * mechanical lithotripsy * cholesterol solvents* cholesterol solvents * extracorporeal shock wave lithotripsy * extracorporeal shock wave lithotripsy
Treatment and Nursing Care: Treatment and Nursing Care: SurgicalSurgical
When is one preferred over another? Why?When is one preferred over another? Why?
________________________
CholecystectomyCholecystectomy * GB removed * GB removed
through through
4 puncture holes4 puncture holes
* CX: injury to CBD * CX: injury to CBD
__________________
CholecystectomyCholecystectomy * removal of GB * removal of GB
via right subcostal via right subcostal
incision incision
* T tube inserted into * T tube inserted into
CBDCBD
Treatment and Nursing Care:Treatment and Nursing Care:Surgical Surgical
Transhepatic Transhepatic
biliary catheterbiliary catheter * to decompress * to decompress
obstructed obstructed
extrahepatic extrahepatic
ducts ducts
Treatment and Nursing Care: Treatment and Nursing Care: Post Op Care &TeachingsPost Op Care &Teachings
Pain ControlPain Control Prevent Prevent
Complications Complications primarily primarily pulmonarypulmonary
Wound CareWound Care Dietary Dietary
modificationmodification
Gerontologic considerationsGerontologic considerations
Gallstones increasingly commonGallstones increasingly common Differing presenting symptomsDiffering presenting symptoms Surgical risks due to concurrent conditionsSurgical risks due to concurrent conditions Decreased elective surgery and more advanced Decreased elective surgery and more advanced
status at time of surgerystatus at time of surgery Higher risk of complications and shorter Higher risk of complications and shorter
hospital stayshospital stays
Gallbladder Cancer Gallbladder Cancer
UncommonUncommon Majority are adenocarcinomasMajority are adenocarcinomas Early symptoms similar to chronic Early symptoms similar to chronic
cholecystitis and cholelithiasischolecystitis and cholelithiasis Later symptoms of biliary obstructionLater symptoms of biliary obstruction Poor prognosisPoor prognosis
Gallbladder CancerGallbladder Cancer
Diagnosis and staging – EUS, transabdominal Diagnosis and staging – EUS, transabdominal US, CT, MRI, MRCPUS, CT, MRI, MRCP
If found early – surgery is curativeIf found early – surgery is curative Extended cholestectomy with lymph node Extended cholestectomy with lymph node
dissection – good outcomedissection – good outcome Palliative – stenting of biliary tree, radiation, Palliative – stenting of biliary tree, radiation,
chemotherapy chemotherapy
Gallbladder CancerGallbladder Cancer
Nursing Management - supportive careNursing Management - supportive care Nutrition, hydration, skin care, pain reliefNutrition, hydration, skin care, pain relief Similar to care for cholecystitis and Similar to care for cholecystitis and
cholelithiasis and cancer cholelithiasis and cancer