Cholelithiasis is the presence of stones in the gallbladder and is the most common disorder of the biliary system. The stones may lodge in the neck of the gallbladder or in the cystic duct. When stones or biliary sludge block the escape of bile from the gallbladder, cholecystitis (inflammation of the gallbladder) may occur. Although cholecystitis is most commonly associated with cholelithiasis, it can also occur in the absence of stones (acalculous cholecystitis). Acalculous cholecystitis occurs most often in older adults and in patients who are critically ill. It is also associated with prolonged immobility and fasting, prolonged parenteral nutrition, and diabetes mellitus. Cholecystitis can also be caused by bacteria reaching the gallbladder via the vascular or lymphatic routes or by chemical irritants in the bile.
During an acute episode of cholecystitis, treatment is supportive and symptomatic. Surgical intervention for cholelithiasis is often indicated and may consist of laparoscopic cholecystectomy or open (incisional) cholecystectomy.
Objectives
Identify risk factors for cholelithiasis and cholecystitis.
Evaluate results of diagnostic testing in a patient with acute cholecystitis.
Describe interprofessional care of a patient with acute cholecystitis.
Prioritize nursing care of a patient with acute cholecystitis.
Develop a nursing care plan for a patient following a laparoscopic cholecystectomy.
Appropriately delegate nursing activities for a postoperative patient following a cholecystectomy.
Develop an individualized teaching plan for a patient following a laparoscopic cholecystectomy.
Case Study
T.W. is a 42-year-old Native American female who is a mother of three children. She also works part-time as an accountant. She is admitted to the medical unit from the emergency department with a diagnosis of possible cholecystitis. She has been vomiting for the past 10 hours and is complaining of severe right upper quadrant (RUQ) pain that radiates to her upper back and scapula. She has had several similar episodes over the last 3 months that were unrelieved by over-the-counter antacids. Last night she had a hamburger and French fries at a fast-food restaurant and a few hours later developed the acute onset of the pain. T.W. weighs 160 lb and is 5 ft 4 in tall. She periodically uses crash diets with fasting or liquid diet preparations but has failed in long-term weight loss. She has mild hypertension that she monitors, and she tries to reduce her salt intake.
The nurse’s initial assessment findings include T.W. being awake, alert, and oriented ×3; sclera appear slightly yellow; breath sounds clear throughout all lung fields; normal, regular heart sounds; bowel sounds active in all four quadrants, abdominal guarding with severe pain on light palpation to right side; skin moist with slightly decreased turgor, no jaundice noticed in skin, but has bruises on her arms and legs; peripheral pulses 3+. Her vital signs are as follows: blood pressure (BP) 120/68 mm Hg, heart rate (HR) 108 beats/min, respiratory rate (RR) 26 breaths/min, and temperature 100.6°F (38.1°C). She reports that her stools have become lighter over the last week and are “frothy.”
The health care provider’s admitting orders include nasogastric tube to low suction, nothing by mouth (NPO), an IV of D5½NS with 20 mEq KCl at 125 mL/hr, ketorolac 10 mg IV q6hr prn for pain, abdominal ultrasound, complete blood count (CBC), electrolytes.
