Cholecystitis Nursing Care Management and Study Guide

Cholecystitis is acute or chronic inflammation of the gallbladder. At the bedside it shows up as right upper quadrant pain, fever, and a rising white count, and your job is to control pain, rest the gallbladder, and catch the patient sliding toward sepsis.

What is Cholecystitis?

Several disorders affect the biliary system and block normal bile drainage into the duodenum. Cholecystitis is the acute or chronic inflammation of the gallbladder.

Classification

Calculous cholecystitis is when a gallbladder stone obstructs bile outflow. Acalculous cholecystitis is acute inflammation without obstruction by gallstones.

Pathophysiology

Calculous and acalculous cholecystitis start differently. In calculous disease, a gallbladder stone obstructs bile outflow. Bile trapped in the gallbladder triggers a chemical reaction, and autolysis and edema follow. Blood vessels in the gallbladder become compressed, compromising its vascular supply.

Statistics and Incidences

Cholecystitis accounts for most patients needing gallbladder surgery. More than 90% of patients with acute cholecystitis have gallstones, though not every case is related to cholelithiasis. The acute form is most common in middle age; the chronic form usually occurs in elderly patients.

Causes

Cholecystitis is usually associated with a gallstone impacted in the cystic duct. Bacteria play a minor role, but secondary infection of bile occurs in about 50% of cases. Acalculous cholecystitis is thought to come from alterations in fluids and electrolytes. Bile stasis, or the lack of gallbladder contraction, also contributes.

Clinical Manifestations

Right upper quadrant pain is the hallmark. Leukocytosis develops as the body fights pathogens, and fever follows the infection. The gallbladder becomes edematous and palpable as infection progresses. If infection reaches the bloodstream, the patient goes septic.

Complications

Empyema develops when the gallbladder fills with purulent fluid. Gangrene develops when the tissue is starved of oxygen and nourishment. Cholangitis develops when infection reaches the bile duct.

Assessment and Diagnostic Findings

Ultrasonography is the preferred initial imaging test; scintigraphy is the preferred alternative. CT is a secondary test that identifies extrabiliary disorders and acute complications, and MRI is another secondary choice for confirming acute cholecystitis. Radiopaque (calcified) gallstones appear on abdominal x-ray in 10% to 15% of cases.

• Biliary ultrasound. Reveals calculi with gallbladder or bile duct distension, often the initial procedure.
• Oral cholecystography (OCG). Visualizes the general appearance and function of the gallbladder, including filling defects, structural defects, or stones in the ducts. Can be done IV (IVC) when nausea or vomiting prevents oral intake, when the gallbladder cannot be seen on OCG, or when symptoms persist after cholecystectomy. IVC may be done preoperatively to assess duct structure and function, detect remaining stones after lithotripsy or cholecystectomy, or detect surgical complications. Dye can also be injected via T-tube drain postoperatively.
• Endoscopic retrograde cholangiopancreatography (ERCP). Visualizes the biliary tree by cannulating the common bile duct through the duodenum.
• Percutaneous transhepatic cholangiography (PTC). Distinguishes gallbladder disease from cancer of the pancreas when jaundice is present, supports a diagnosis of obstructive jaundice, and reveals calculi in the ducts.
• Nonnuclear CT scan. May reveal gallbladder cysts, dilation of bile ducts, and distinguish obstructive from nonobstructive jaundice.
• Hepatobiliary (HIDA, PIPIDA) scan. Confirms cholecystitis, especially when barium studies are contraindicated; may be combined with cholecystokinin injection to demonstrate abnormal gallbladder ejection.
• Chest x-ray. Rules out respiratory causes of referred pain.
• CBC. Moderate leukocytosis in acute disease.
• Serum bilirubin and amylase. Elevated.
• Serum liver enzymes (AST, ALT, ALP, LDH). Slight elevation; alkaline phosphatase and 5-nucleotidase are markedly elevated in biliary obstruction.
• Prothrombin levels. Reduced when obstructed bile flow decreases absorption of vitamin K.

Medical Management

The patient may be kept NPO at first to take stress off the inflamed gallbladder, with IV fluids for support. Supportive care includes restoring hemodynamic stability and antibiotic coverage for gram-negative enteric flora. Daily stimulation of gallbladder contraction with IV cholecystokinin may prevent gallbladder sludge in patients on TPN.

Pharmacologic Therapy

• Antibiotics. Levofloxacin and Metronidazole for prophylactic coverage against the most common organisms.
• Antiemetics. Promethazine or Prochlorperazine control nausea and prevent fluid and electrolyte disorders.
• Analgesics. Oxycodone or Acetaminophen control symptoms and reduce pain.

Surgical Management

Because cholecystitis frequently recurs, most patients eventually need gallbladder removal. Cholecystectomy is most often done with a laparoscope. ERCP visualizes the biliary tree by cannulating the common bile duct through the duodenum.

Nursing Management

Nursing Assessment

Assess the skin and mucous membranes, peripheral pulses and capillary refill, and the abdomen for distension, frequent belching, guarding, and reluctance to move. Watch for unusual bleeding: oozing from injection sites, epistaxis, bleeding gums, petechiae, ecchymosis, hematemesis, or melena.

Nursing Diagnosis

• Acute pain related to the inflammatory process.
• Risk for imbalanced nutrition related to self-imposed dietary restrictions and pain.

Nursing Care Planning & Goals

Goals are to relieve pain and promote rest, maintain fluid and electrolyte balance, prevent complications, and teach the patient about the disease process, prognosis, and treatment.

Nursing Interventions

Observe and document the location, severity (0 to 10 scale), and character of pain. Promote bedrest in a position of comfort and encourage relaxation techniques and diversional activity. Make time to listen and stay in frequent contact. Calculate caloric intake to identify deficiencies, ask about likes, dislikes, foods that cause distress, and preferred meal times, and provide a pleasant mealtime free of noxious stimuli. Monitor labs: BUN, pre-albumin, albumin, total protein, and transferrin.

Evaluation

Confirm the patient meets the planned goals: pain relieved, homeostasis achieved, complications prevented or minimized, and the disease process, prognosis, and regimen understood.

Discharge and Home Care Guidelines

Teach the patient the causes of the disease, the complications of leaving it untreated, and the medical and surgical options. Have them ambulate and increase activity as tolerated, and consult a dietitian to establish individual nutritional needs.

Documentation Guidelines

Document the client's description and inventory of pain, expectations of pain management, acceptable pain level, prior medication use, caloric intake, cultural or religious restrictions and personal preferences, availability and use of resources, the plan of care, the teaching plan, response to interventions and teaching, progress toward outcomes, and any modifications to the plan.

Practice Quiz: Cholecystitis

1. The initial course of treatment for a patient with cholecystitis may include:

A. Analgesics and antibiotics B. Intravenous fluids C. Nasogastric suctioning D. All of the above

Answer: D. Analgesics and antibiotics are primary medications, and nasogastric suctioning helps prevent gastric sludge. Options A, B, and C are all part of treatment.

2. A patient with cholecystitis is limited to low-fat liquids. As foods are added, which should be avoided?

A. Cooked fruits B. Eggs and cheese C. Lean meats D. Rice and tapioca

Answer: B. Eggs and cheese are rich in cholesterol, which is contraindicated. Cooked fruits are high in fiber, lean meats are low in fat, and rice and tapioca are mostly carbohydrate.

3. Postoperative nursing observation includes assessing for:

A. Indicators of infection B. Leakage of bile into the peritoneal cavity C. Obstruction of bile drainage D. All of the above

Answer: D. Assessing for infection, bile leakage, and obstruction of bile drainage are all appropriate postoperatively.

4. Marie, a 51-year-old woman, is diagnosed with cholecystitis. Which diet choice shows teaching was successful?

A. 4 to 6 small meals of low-carbohydrate foods daily B. High-fat, high-carbohydrate meals C. Low-fat, high-carbohydrate meals D. High-fat, low-protein meals

Answer: C. Fat intake should be reduced, with calories from fat replaced by carbohydrate. Reducing carbohydrate is contraindicated, and any high-fat diet may trigger another attack.

5. Which clinical manifestation would the nurse expect in acute cholecystitis?

A. Jaundice, dark urine, and steatorrhea B. Acute right lower quadrant pain, diarrhea, and dehydration C. Ecchymosis, petechiae, and coffee-ground emesis D. Nausea, vomiting, and anorexia

Answer: D. Acute cholecystitis commonly presents with anorexia, nausea, and vomiting. Jaundice, dark urine, and steatorrhea point to the icteric phase of hepatitis; RUQ tenderness and rigidity with a positive Murphy's sign, fever, and fat intolerance point to biliary colic; ecchymosis, petechiae, and coffee-ground emesis point to esophageal bleeding.