Gallbladder disorder

The gallbladder stores and concentrates bile produced by the liver.

The hormone cholecystokinin, secreted by the small intestine,
stimulates contraction of the gallbladder and relaxation of the
sphincter of Oddi for delivery of bile into the small intestine.

Bile aids function in fat emulsification (breakdown); absorption

of fatty acids, cholesterol, and other lipids from the small intestine;
and excretion of conjugated bilirubin from the liver.Cholelithiasis is
the presence of stones in the gallbladder. Cholecystitis is
inflammation of the gallbladder (may be acute or chronic).
Choledocholithiasis is the presence of stones in the common bile
duct.

Pathophysiology /Etiology :A. Cholelithiasis

1- Stones occur when cholesterol supersaturates the bile in the

gallbladder and precipitates out of the bile. The cholesterol-
saturated bile predisposes to the formation of gallstones and
acts as an irritant, producing inflammatory changes in the
gallbladder.
2- .Pigment stones occur when free bilirubin combines with
calcium.

 Found in patients with cirrhosis, hemolysis, and infections in

the biliary tree.

 These stones cannot be dissolved.

 Incidence of stone formation increases with age due to

increased hepatic secretion of cholesterol and
decreased bile acid synthesis.

 Increased risk in patients with malabsorption of bile

salts with GI disease, carcinoma of the gallbladder,

 Stone formation increases in users of contraceptives,

estrogens, and cholesterol-lowering drugs, which are
known to increase biliary cholesterol saturation

B – Cholecystitis

 Acute cholecystitis is an acute infection of the gallbladder.

 Most cases are caused by gallstone obstruction of the cystic
duct, causing edema, inflammation, and bacterial invasion.
This is called calculous cholecystitis.
  Acalculous cholecystitis is acute gallbladder inflammation in
the absence of obstruction by gallstones.( Occurs after major
surgical procedures, severe trauma, or burns.)

 Chronic cholecystitis occurs when the gallbladder becomes

thickened, rigid, and fibrotic and functions poorly.( Results
from repeated attacks of cholecystitis, presence of calculi,)

Clinical Manifestations

1- Biliary colic can be caused by the presence of

gallstones.

 Steady, severe aching pain or sensation of pressure in the

epigastrium or right upper quadrant, which may radiate to the
right scapular area or right shoulder.
 Begins suddenly and persists for 1 to 3 hours until the stone
falls back into the gallbladder or is passed through the cystic
duct.

2- Acute cholecystitis causes biliary colic pain that persists more

than 4 hours and increases with movement, including respirations.

 Also causes nausea and vomiting, low-grade fever, and

jaundice (with stones or inflammation in the common bile duct).
 Right upper quadrant guarding and Murphy’s sign (inability to
take a deep inspiration when examiner’s fingers are pressed below
the hepatic margin) are present.

Management

 Supportive management includes: rest, IV fluids, pain

management, and antibiotics (in the presence of a positive culture).
 Surgical management.:

- Cholecystectomy, open or laparoscopic.

- Placement of a T-tube in the common bile duct to

decompress the biliary tree and allow access into the biliary tree
postoperatively.

- Intracorporeal lithotripsy is used to fragment stones in

the gallbladder or common bile duct by ultrasound, pulsed laser, or
hydraulic lithotripsy applied through an endoscope directly to the
stones. The stone fragments are removed by irrigation and
aspiration. A cholecystectomy may then be performed.

Cholecystectomy is the surgical removal of the gallbladder for acute

and chronic cholecystitis.
 done through open laparotomy (gallbladder removed after making
an abdominal incision) or laparoscopy (gallbladder removed from a
small opening just above the umbilicus by the use of a laparoscope
for viewing). During laparoscopy, three other small punctures are
made in the abdomen to place other special instruments used to
assist in removal and manipulation of the gallbladder. The organs in
the abdomen can be viewed through the laparoscope as well as on
a television monitor through a camera attached to the laparoscope.

Complications

 Necrosis, empyema, or perforation of the

gallbladder
 Adenocarcinoma of the gallbladder

NURSING CARE PLAN

HEALTH HISTORY:

Admission chief complain and history of present illness:

Male patient 45 year old admitted to surgical male ward as cas of gallbladder stone
Before one month patient complain from sever pain in general abdomen area at
12:00 am this pain lasted fro 1 hour scale 6 \10 on pain scale the this pain was
disappear and after tow hours this pain was reappear but in more severe mood
concentrate in right upper guardant radiated to right shoulder not relief by change
position this lead patient to go to al yarmook hospital and he take an one ampoule of
vortex injection then patient come back to his home and after breakfast in morning
this pain come back this lead patient to go to doctor .doctor tell patient he must
remove gallbladder but patient reject in that time because he was busy in his working
until 20/12/2005 pain come back in uncomfortable mood then patient go to doctor
and doctor was admitted him to s.m as case of gallbladder stone

History of past illnesses:

In 1985 hernia repair , no other disease with patient or hospitalization , no HTN or

DM.

PHYSICAL EXAMINATION:

General appearance:
Pulse rate: 71 B/M Temperature: 37.2 cº

B.P: 120/70 R.R :18 /M

Pallor, fatigued and extremely ill

patient oriented to time place and persons

Respiratory System:

Respiratory rate: 18 Breath per minute

Respiratory rhythm: regular

No wheezing and no crackles

patient can’t take deep breathing because he feel pain in surgical area

heart :

no murmurs , normal s1,s2 sounds

nervous system :

patient conscious , patient oriented to time , place , persons . no peripheral

sensation loss .

Musculoskeletal system:

no involuntary movement , no activity limitations, No stiffness in neck .

abdomen :

normal color , no cyanosis , no accumulation fluid in abdomen , no

umbilicus herniation , 17 cm surgical incision. no bleeding from surgical
site , no discharge from surgical incision , pain around surgical area .

gastrointestinal :

no heart burn , anorexia ,

Diagnostic test :

Name Range
Normal Nursing
range note
Glucose 4.2-6.4 elevate
7.6mmol mmol/L d
/l
 WBC 11.3 4- high
11*10^3/m
RBC 5.9 4.5- Normal
6*10^6m
PLT 499 150- high
450*10M
Na 144.2 135- normal
148meq/L
Ca 1.3 2-2.6mmol/L low
K 3.72 3.5- normal
5.3meq/L
creatini 65 53 – normal
n 115umol\L
Pt 10s 11 – 16 s normal
Ptt 32s 21 –45 s normal
albumin 117 34-55g\l high
Totalbilir 6 5.1- normal
ubine 17.1mmol\l
amylase 47 0-95u\l normal

Diagnostic procedure : CBC , abdomen x-ray

Medication

Name Action Classi Do Side effect Nurs. Cons.

ficatio s
n
zantac Competitively inhibits H2 50m Constipation, Decrease doses
the action of histamine antagon g\ diarrhea, in renal and
at the histamine2 (H2) ist I.V
receptors of the parietal q8h
nausea, liver failure.
cells of the stomach, vomiting,
inhibiting gastric acid
secretion that is
stimulated by food
plasil stimulates motility of Antieme 10g Nausea, Monitor BP
upper GI tract without tic m\ diarrhea carefully during
stimulating gastric, GI IV IV administration
biliary, or pancreatic stimula q8h
secretions; nt
Clafor inhibits synthesis of Antibioti 1 Nausea, Discontinue if
bacterial cell wall, c gm vomiting, hypersensitivity
an causing cell death. Cephalo \ iv
sporin q8h
diarrhea, reaction occurs.
third anorexia
generati
on

Nursing Assessment :

Subjective data:

Patient said : he feel pain in surgical area not relief by change

position increase by coughing, walking and setting (pain scale6 from
10 ).

Patient said : he doesn’t know about this disease that happened

with him and he doesn’t know about the diet.

Patient said : he doesn’t know how to care surgical site

Patient said : he afraid from death and hospitalization

Patient said : he doesn’t drink because he afraid from vomiting

Objective data:

Pulse rate: 71 B/M Temperature: 37.2ºc

Pallor, fatigued and extremely ill

ultra sound : multiple gallbladder stone

Respiratory rate:18 Breath per minute

Respiratory rhythm: regular breathing , conscious , Low level of

knowledge about disease

patient oriented to time , persons , place .

patient now restricted from food just fluids and soup ., no bleeding in
surgical area .

albumin ,PLT, Glucose, WBC elevated

patient take medication ( illustrated in the table above ) .

Nursing Diagnoses 1:

Pain related to surgical incision as manifested by patient

verbalization
Planning :

Goal : Relieving Pain Postoperatively

Ex. outcome : patient well able to verbalize has less pain

(decreased from 6 to 4 on pain scale) at the end of my shift.

Nursing Interventions :

 Have the patient splint the incision site with hand or pillow
when coughing to lessen pain and protect site from increased
intraabdominal pressure. Splinting and proper positing reduce
the stress on the incision area.
 Provide therapeutic environment—proper temperature and
humidity, ventilation, visitors to decrease the tension on
patient .

 Put patient in comfort position to decrease pressure on

surgical incision

 Explaining pain relief methods, such as Breathing exercises,

heat application, and progressive relaxation because
Breathing exercises and relaxation techniques decrease
oxygen consumption, respiratory rate, heart rate, and muscle
tension, which interrupt the cycle of pain–anxiety–muscle
tension

 Administer analgesics, as doctor ordered .

Evaluation :

 Goal met . patient verbalize has less pain (decreased

from 6 to 4 on pain scale)

Nursing Diagnoses 2 :

Impaired Skin Integrity related to invasive procedure as

manifested by surgical incision .

Planning :

Goal : improving Skin Integrity

Ex. outcome : patient will be free from impairment skin

integrity

Nursing Interventions :
  Assess wound for signs of swelling, and purulent drainage,
which may indicate infection
 Perform hand washing before and after contact with patient
to prevent contamination .

 Inspect dressings routinely and change it if necessary

 Record amount and type of wound drainage

 Turn patient frequently or encourage position changes to

prevent skin breakdown at pressure areas.

 Keep suture line clean, never vigorously rub near suture

line .

Evaluation :

Goal not met because wound healing need more than one
shift care to maintain skin integrity

Nursing Diagnoses 3 :

Knowledge deficit about disease and about wound care

Planning :

Goal : Educating the Patient

Ex. outcome : patient will be have good knowledge

about disease and about wound care at the end of my
shift .

Nursing Interventions :

 Encourage questions to answer about illness .

 Describe illness and relate symptom of hernia .

 Answer questions honestly and completely at appropriate

level .

 Teach patient how to care wound and how to promote

healing .

 Explain all procedure and treatment and the rational for

them .

 Teach patient about wound care and abut early sings of

infection .
Evaluation :

Goal met . Patient have good knowledge about

disease and about wound care

Nursing Diagnoses 4 :

Anxiety related to fear of death and hospitalization

as manifested by patient verbalization .

Planning :

Goal : Decreasing Anxiety

Ex. outcome : patient will be free from anxiety

.Nursing Interventions :

 Explain to the patient and family reasons for

hospitalization, diagnostic tests, and therapies
administered to decrease the fear of hospitalization .
 Encourage the patient to verbalize fears and concerns
regarding illness through frequent conversations—conveys
to the patient a willingness to listen.

 Answer the patient questions with concise explanations.

 Describe illness and relate symptom of diseases to notify

the patient about any complication of Cholecystectomy, .

 Explain all procedure and treatment and the rational for

them .

Evaluation :

Goal partially met patient now have no fear

about his disease

Nursing Diagnoses 4 :

Risk for Fluid volume deficit related to impaired fluid intake,

vomiting, as manifested by patient verbalization.

Planning :

Goal : Maintaining Electrolyte and Fluid Balance

Ex. outcome : patient will be free from signs of dehydration

or electrolyte imbalance during my shift.
Nursing Interventions :

 Measure and record all intake and output to maintain fluid

balance
 Administer IV fluids as doctor order to prevent dehydration

 Monitor electrolytes, urinalysis, hemoglobin, and blood cell

counts and report any abnormalities to identify any
abnormalities in early stages and treat it .

 Monitor vital signs; a drop in blood pressure may indicate

decreased circulatory volume due to blood loss from
surgical procedure .

Evaluation :

Goal met . patient now free from signs of dehydration or

electrolyte imbalance.

Nursing Diagnoses 5 :

Risk for Infection related to surgical incision

Planning : Goal : Prevent Infection

Ex. outcome : patient will be free from sign

and symptom of infection during my shift

Nursing Interventions :

 Check dressing for drainage and incision for redness and

swelling.
 Instruct patient to avoid touching incision to minimize
wound contamination and injury.

 Assess and accurately document condition of incision site

each shift.

 Keep suture line clean (may shower unless contraindicated

by health care provider; avoid tub bathing until wound
heals); never vigorously rub near suture line, pat dry.

 Monitor for other signs/symptoms of infection: fever, chills,

malaise, diaphoresis.

 Administer antibiotics as order

Evaluation : Goal met : patient now free from sign and

symptom of infection .