Nursing Care for Patients with Gallbladder Disorders PDF

Nursing care for patient with Gallbladder Disorders Prepared By Assist Professor Dr. Haider Mohammed AL-Abedi 1  Gallbladder Disorders Outlines Cholecystitis Cholelithiasis 2  Learning Outcome Explain the causes, risk...

Nursing care for patient with Gallbladder Disorders Prepared By Assist Professor Dr. Haider Mohammed AL-Abedi 1  Gallbladder Disorders Outlines Cholecystitis Cholelithiasis 2  Learning Outcome Explain the causes, risk factors, and pathophysiology of gallbladder disorders. 3  Overview Gallbladder The gallbladder, a pear-shaped, hollow, saclike organ that is 7.5 to 10 cm (3 to 4 inches) long, lies in a shallow depression on the inferior surface of the liver, to which it is attached by loose connective tissue. The capacity of the gallbladder is 30 to 50 mL of bile. Its wall is composed largely of smooth muscle. The gallbladder is connected to the common bile duct by the cystic duct 4  Overview The gallbladder functions as a storage depot for bile. Between meals. when the sphincter of Oddi is closed, bile produced by the hepatocytes enters the gallbladder. When food enters the duodenum, the gallbladder contracts and the sphincter of Oddi (located at the junction of the common bile duct with the duodenum) relaxes. Relaxation of this sphincter allows the bile to enter the intestine. This response is mediated by the secretion of the hormone cholecystokinin (CCK) from the intestinal wall. CCK is the major stimulus for digestive enzyme secretion and acts by stimulating the gallbladder to contract. 5 6  The bile salts, together with cholesterol, assist in the emulsification of fats in the distal ileum. They are then reabsorbed into the portal blood for return to the liver, after which they are once again excreted into the bile. This pathway from hepatocytes to bile to the intestine and back to the hepatocytes is called enterohepatic circulation. Because of this circulation, only a small fraction of the bile salts that enter the intestine are excreted in the feces. 7  CHOLECYSTITIS 8  Cholecystitis Cholecystitis (inflammation of the gallbladder which can be acute or chronic) causes pain, tenderness, and rigidity of the upper right abdomen that may radiate to the midsternal area or right shoulder and is associated with nausea, vomiting, and the usual signs of an acute inflammation. An empyema of the gallbladder develops if the gallbladder becomes filled with purulent fluid (pus). 9  Types Calculous cholecystitis is the cause of more than 90% of cases of acute In calculous cholecystitis, a gallbladder stone obstructs bile outflow. Bile remaining in the gallbladder initiates a chemical reaction; autolysis and edema occur; and the blood vessels in the gallbladder are compressed, compromising its vascular supply. 10  Types Gangrene of the gallbladder with perforation may result. Bacteria play a minor role in acute cholecystitis; however, secondary infection of bile occurs in approximately 50% of cases. The organisms involved are generally enteric (normally live in the GI tract) and include Escherichia coli, Klebsiella species, and Streptococcus. Bacterial contamination is not believed to stimulate the actual onset of acute cholecystitis. 11  Types Acalculous cholecystitis describes acute gallbladder inflammation in the absence of obstruction by gallstones. Acalculous cholecystitis occurs after major surgical procedures, orthopedic procedures, severe trauma, or burns. Other factors associated with this type of cholecystitis include torsion, cystic duct obstruction, primary bacterial infections of the gallbladder, and multiple blood transfusions. 12  Pathophysiology Cholecystitis is an acute or chronic inflammation of the gallbladder. It is most often a response to obstruction of the common bile duct resulting in edema and inflammation.  Pathophysiology Bacteria can invade stagnant bile and add to the inflammation and irritation of the gallbladder. Chronic cholecystitis may be the result of repeated attacks of acute cholecystitis or chronic irritation from gallstones. The gallbladder then becomes fibrotic and thickened and does not empty easily or completely. This is a risk factor for gallbladder cancer.  Signs and Symptoms The biliary colic caused by cholecystitis typically lasts 4 to 6 hours. The pain is made worse with movement such as breathing. The patient usually has nausea vomiting, and a low- grade fever with the pain. Heartburn, indigestion, and flatulence are more common with chronic cholecystitis. Patients often report repeated attacks of acute cholecystitis symptoms 15  Diagnosis USG X-ray abdomen Blood test- increased WBC CT scan 16  Management Medical: Hospitalization Antibiotic therapy Analgesic Antacid Antiemetic Provide comfort measure Monitor fluid and electrolyte Surgical : Cholecystectomy (Open or Laparoscopy) 17  Nursing Management Assessment: Characteristics of pain, presence of pain in relation to ingestion of food high in fat Abdomen for tenderness. Stools for color, character of urine. Nursing diagnosis Pain related to inflammation of gall bladder Increase body temperature related to inflammation of gall bladder Fear and anxiety related to disease condition and it’s prognosis. 18  CHOLELITHIASIS 19  CHOLELITHIASIS Introduction It is a common disorder of biliary system. The term “cholelithiasis” is derived from the Greek word “chole” meaning “bile”, “lith”, meaning “stone” & “iasis” meaning “process”. Therefore, the process of stone formation in the bile (gall bladder) is known as cholelithiasis. These stones are composed of cholesterol, bile pigments and calcium. 20  Cholelithiasis Cholelithiasis: Calculi, or gallstones, usually form in the gallbladder from the solid constituents of bile; they vary greatly in size, shape, and composition. They are uncommon in children and young adults but become increasingly prevalent after 40 years of age.  Cholelithiasis 22  Types of gallstone - Cholesterol stones - Cholesterol stones account for most of the remaining 75% of cases of gallbladder disease in the United States. Cholesterol, which is a normal constituent of bile, is insoluble in water. Its solubility depends on bile acids and lecithin (phospholipids) in bile.  Types of gallstone - Cholesterol stones - In gallstone-prone patients, there is decreased bile acid synthesis and increased cholesterol synthesis in the liver, resulting in bile supersaturated with cholesterol, which precipitates out of the bile to form stones. - The cholesterol-saturated bile predisposes to the formation of gallstones and acts as an irritant that produces inflammatory changes in the mucosa of the gallbladder.  Types of gallstone Pigment stones - Pigment stones probably form when unconjugated pigments in the bile precipitate form stones; these stones account for about 10% to 25% of cases in the United States - The risk of developing such stones is increased in patients with cirrhosis, hemolysis, and infections of the biliary tract. Pigment stones cannot be dissolved and must be removed surgically. 26  Etiology Gallstones occur most in women, from aging, obesity, pregnancy, stasis of bile, fasting, medications, and heredity. Stasis may be caused by a decreased gallbladder-emptying rate, a partial obstruction in the common duct, or pregnancy. Excessive cholesterol intake combined with a sedentary lifestyle is linked to an increased incidence of cholelithiasis, as are hemolytic blood disorders such as sickle cell disease and bowel disorders such as Crohn’s disease. After age 50, the rate of gallstones is about the same for men and women 27  Pathophysiology Cholelithiasis is the formation of gallstones in the gallbladder that are most often composed of cholesterol in the United States. They can be asymptomatic for decades. Choledocholithiasis refers to gallstones within the common bile duct. Gallstones form when bile becomes supersaturated with a substance such as cholesterol, which then crystallizes, forming sludge with continued enlargement to form stones. Pigment stones are composed of calcium bilirubinate, which occurs when free bilirubin combines with calcium. 28  Clinical Manifestations The epigastric pain caused by cholelithiasis may also be called biliary colic. 1. The pain is a steady, aching, severe pain in the epigastrium and RUQ that may radiate back to behind the right scapula or to the right shoulder. The pain usually begins suddenly after a fatty meal and lasts for 1 to 3 hours. If the pain is caused by a stone in the common bile duct (choledocholithiasis), the pain may last until the stone has passed into the duodenum. Biliary colic is usually associated with nausea and vomiting, and it is noticeable several hours after a heavy meal. The patient moves about restlessly, unable to find a comfortable position. 29  Clinical Manifestations 2. Jaundice occurs in a few patients wit gallbladder disease, usually with obstruction of the common bile duct. The bile, which is no longer carried to the duodenum, is absorbed by the blood and gives the skin and mucous membranes a yellow color. This is frequently accompanied by marked pruritus (itching) of the skin. 30  Clinical Manifestations 3. Changes in Urine and Stool Color: The excretion of the bile pigments by the kidneys gives the urine a very dark color. The feces, no longer colored with bile pigments, are grayish (like putty) or clay colored. 4. Vitamin Deficiency Obstruction: of bile flow interferes with absorption of the fat-soluble vitamins A, D, E, and K. Patients may exhibit deficiencies of these vitamins if biliary obstruction has been prolonged. For example, a patient may have bleeding caused by vitamin K deficiency (vitamin K is necessary for normal blood clotting). 31 Assessment and Diagnostic Findings  Complications Complications of cholecystitis include cholangitis (inflammation of the bile ducts), necrosis or perforation of the gallbladder, empyema (a collection of purulent drainage in the gallbladder), fistulas, and adenocarcinoma of the gallbladder. A major complication of choledocholithiasis is acute pancreatitis if the pancreatic duct is obstructed. 33  Medical Management Nutritional And Supportive Therapy The patients with acute gallbladder inflammation achieve remission with rest, intravenous fluids, and nasogastric suction. surgical intervention is delayed until the acute symptoms subside. The diet immediately after an episode is usually limited to low-fat liquids.  Pharmacologic Therapy Ursodeoxycholic acid (UDCA) and chenodeoxycholic acid (chenodiol or CDCA) have been used to dissolve small. UDCA has fewer side effects than chenodiol and can be administered in smaller doses to achieve the same effect. It acts by inhibiting the synthesis and secretion of cholesterol. Existing stones can be reduced in size, small ones dissolved, and new stones prevented from forming.  Surgical Management Laparoscopic Cholecystectomy: is performed through a small incision or puncture made through the abdominal wall in the umbilicus. to assist in inserting the laparoscope and to aid the surgeon in visualizing the abdominal structures. Cholecystectomy: In this procedure, the gallbladder is removed through an abdominal incision Mini-cholecystectomy : is a surgical procedure in which the gallbladder is removed through a small incision. Choledochostomy : involves an incision into the common duct, usually for removal of stones  Nursing Diagnoses Acute pain and discomfort related to surgical incision Impaired gas exchange related to the high abdominal surgical incision (if traditional surgical cholecystectomy is performed) Imbalanced nutrition, less than body requirements, related to inadequate bile secretion Deficient knowledge about self-care activities related to incision care, dietary modifications (if needed), medications, reportable signs or symptoms (eg, fever, bleeding, vomiting)  Planning Relief of pain Adequate ventilation Optimal nutritional intake  Nursing Interventions RELIEVING PAIN Activity are necessary to prevent postoperative complications, the nurse should administer analgesic agents as prescribed to relieve the pain and to promote well-being in addition to helping the patient turn, cough, breathe deeply, and ambulate as indicated. Use of a pillow or binder over the incision may reduce pain during these maneuvers. Improving Nutritional Status * The nurse encourages the patient to eat a diet low in fats and high in carbohydrates and proteins immediately after surgery. * Maintain a nutritious diet and avoid excessive fats.. Improving Respiratory Status Patients undergoing biliary tract surgery are especially prone to pulmonary complications, as are all patients with upper abdominal incisions. patients to take deep breaths and cough every hour to expand the lungs fully and prevent atelectasis. use of incentive spirometry also helps improve respiratory function. Early ambulation prevents pulmonary complications  References Hinkle, J. L., & Cheever, K. H. (2018). Brunner and Suddarth’s textbook of medical-surgical nursing. Wolters kluwer india Pvt Ltd.p.113-114. Williams, L. S., & Hopper, P. D. (2015). Understanding medical surgical nursing. FA Davis.. 42  THINK YOU 43