Medical Diagnosis: Cholecystitis/Cholelithiasis
Nursing Diagnosis: Activity intolerance r/t laparoscopic abdominal incisions AEB SOB during ambulation, increased respirations at 38, O2 sat 80% room air after walking 50 ft.
Normal Physiology: The gallbladder is situated inferior to the liver. The gallbladder is a structure that functions as a storage space for bile that is produced in the liver. The liver produces and secretes bile into the gallbladder from the right and left hepatic duct join together to become the common hepatic duct then into the gallbladder via the cystic duct. During the digestion of fatty food, the gallbladder releases bile that passes through the common bile duct and into the duodenum through the Sphincter of Oddi to break down fat into fatty acids to be absorbed by the small intestine to be used as energy and storage of energy for metabolic needs of the body.
Cholecystitis, and inflammation of the gallbladder, is a condition which can be caused by cholelithiasis, the formation of gallstones. Most stones are formed of cholesterol. Excess cholesterol in bile is associated with obesity, high cholesterol diet and drugs that are prescribed to lower cholesterol levels. The excess saturation of cholesterol can lead to the formation of stones. This client had an elevated LDL and low HDL levels that do state the client had excess cholesterol. Biliary stasis, which is slow emptying of the gallbladder, can also cause the formation of stones. An inflammation of the gallbladder allows for excess water and bile salt reabsorption which call also lead to the formation of stones. This client did have wall thickening and distention of the gallbladder that indicates a inflammation of the gallbladder over a period of time. This is the second time the client came to the ER with pain in a 6 week period.
Potential Complications: If a gallstone migrates out of the gallbladder into the ducts, it can lead to cholangitis which is an inflammation of the duct. Obstruction of the common bile duct may cause bile reflux into the liver causing pain, jaundice, and liver damage. The clients ALT, liver function test was elevated indicating liver disease process and in this clients case it is due to the back-up of bile into the liver from obstruction in the common bile duct. The client can also have pancreatitis due to the inability of the pancreas to secrete digestive enzymes through the pancreatic duct. The client had mild pancreatitis confirmed by CT scan. Complications of the cholecystitis/cholelithiasis can lead to a collection of infected fluid within the gallbladder, gangrene, and perforation resulting in peritonitis or abscess formation. A fistula into adjacent organs can for such as in the duodenum the colon or stomach. During the laparoscopic cholecystectomy, the client’s gallbladder was noted with gangrene but no perforation, peritonitis, fistula or abscess formation was noted. If this condition goes untreated, death can result from hemorrhage, peritonitis, hypovolemic shock, septicemia and septic shock. The client did not die because treatment and surgery was performed.
Nursing Interventions & Rationales:
1. Ambulate with client 1:1 assist. The client should not ambulate alone. The client is at risk for falls for injury to do her activity intolerance for SOB and decreased O2 sats. This will ensure the client does not fall and if she does become weak or unstable it will reduce the injury. 2. Place the client in semi-fowler during resting time in bed. This will decrease orthopnea and help the client breath better by decreasing pressure on the diaphragm allowing for better expansion of the lungs. 3. Monitor respiratory status and auscultate lung sound every 4 hours. This will help assess interventions and any changes needed for their respiratory status. Dependent:
4. Monitor and assess clients...