cholecystectomy
Content
IN-DEPTH VIEW ON CHOLECYSTECTOMY
Case study presented by Group 22 BSN 206
CLINICAL VIEW Ever wonder whom, when, where, what surgery was before? How was it evolved? At present, surgery is a medical specialty that uses operative manual and in insstru rum mental techniq iqu ues on a patie ien nt to investigate
and/or treat a pathological condition such as disease or injury, to help improve bodily function or appearance, and sometimes for religious reasons. Surgery originated from the Latin word chirurgia or in Greek word ch chei eir r and er erg gon whi hich ch mea eans ns ha hand nd work rk.. As sur urg ger ery y was de defi fine ned d as hand work in early times, it was done through trepanation or the drilling a hole into the skull in which earlier beliefs it would treat health problems related to intracranial pressure and other diseases in which evid iden encces suggested those who had undergone trephining had survived. As inven enti tion onss of sc scie ien nti tissts con onti tinu nuou ousl sly y evolving aft fter er yea earrs and yea earrs, we have now di diff ffer eren entt con onsi side derrati tion onss pr prio iorr to th the e pr proc oced edu ure li lik ke th the e pr prin inci cipl ple e of aseptic technique. Every in ind divid idu ual alive today, the highest as well as the lo low wes est, t, is de deri rived in an un unbr bro oken li line ne fr fro om th the e fi firrst and lo low wes estt form rms. s.
CLINICAL VIEW Ever wonder whom, when, where, what surgery was before? How was it evolved? At present, surgery is a medical specialty that uses operative manual and in insstru rum mental techniq iqu ues on a patie ien nt to investigate
and/or treat a pathological condition such as disease or injury, to help improve bodily function or appearance, and sometimes for religious reasons. Surgery originated from the Latin word chirurgia or in Greek word ch chei eir r and er erg gon whi hich ch mea eans ns ha hand nd work rk.. As sur urg ger ery y was de defi fine ned d as hand work in early times, it was done through trepanation or the drilling a hole into the skull in which earlier beliefs it would treat health problems related to intracranial pressure and other diseases in which evid iden encces suggested those who had undergone trephining had survived. As inven enti tion onss of sc scie ien nti tissts con onti tinu nuou ousl sly y evolving aft fter er yea earrs and yea earrs, we have now di diff ffer eren entt con onsi side derrati tion onss pr prio iorr to th the e pr proc oced edu ure li lik ke th the e pr prin inci cipl ple e of aseptic technique. Every in ind divid idu ual alive today, the highest as well as the lo low wes est, t, is de deri rived in an un unbr bro oken li line ne fr fro om th the e fi firrst and lo low wes estt form rms. s.
CLINICAL VIEW Ther ere e
are nu num merous sur urg gic ica al pr pro oced edur ures es in our ti tim mes es.. Our group was able to ass ssis istt in unusual sur urg gical procedure which was cholec ecy ystectomy. Cholecystectomy is the surgical procedure done to remove the gall bla ladd dder er fr fro om wh whic ich h it may be in infl flam amed ed,, in inffec ectted ed,, or obs bstr truc uctted by a stone ne.. We focused our study on two diseases associated with the gall bladder. These are cholelithiasis and cholecystitis. Both terms might sound the same and associated with the gall bladder but does not mean the same disease process. Cholelithiasis is the presence of gallstones in the gall blad bl adde derr, wh whil ile, e, ch chol olec ecy ysti titi tiss is th the e in infl flam amm mati tio on of th the e gal allb lbla ladd dder er,, us usua uall lly y resu re sult ltin ing g fr from om a gal alls lstton one e bl blo ock ckin ing g th the e cy cyssti ticc du duct ct.. As de defi fine ned, d, ch chol olec ecy yst stit itis is may have an incidence of occurring when a person has cholethiasis in which its gallstones would obstruct that causes inflammation. Both dis ise eases have similarities and differences on the signs and symptoms dep epen end ding on its condit itiion. As this cas ase e study will be disc scu uss ssed ed,, a detailed explanatio ion n on the diseas ase e process and its interventions done to remove the cause of the disease. Also what would be the nursing management when havin ing g a sur urg gic ica al cas ase e of ch cho ole lecy cysstec ecttomy pr preo eop peratively and postoperatively.
CLINICAL VIEW One of our concepts on gastrointestinal metabolism was able to associate in our related learning experience, surgery conce cep pt which was chole lecy cysstectomy. Through the experience the group had, it helped us entirely visualize and know by heart how the surgical procedure was done; what to do and to what be aware of. Though the group had a problem with surgery skills laboratory, the combined theoretical and actual procedure in the area, gave knowledge and skill that made it handy to be prepared on other procedures that might be handling in the next cases. You just don't luck into things as much as you'd like to think you do. You build step by step, whether it's frien fri endsh dship ipss or op oppo portu rtunit nities. ies.
ANATOMY/STRUCTURE/ FUNCTION Cholecystectomy
is the surgical removal of the gallbladder. It is the most common method for treating symptomatic gallstones. Surgical options include the standard procedure, called laparoscopic cholecystectomy, and an older more invasive procedure, called open cholecystectomy.
OPEN CHOLECYSTECTOMY
In open gallbladder surgery (cholecystectomy), the surgeon removes the gallbladder through a single, large incision in the abdomen. You will need general anesthesia, and the surgery lasts 1 to 2 hours. The surgeon will make the incision either under the border of the right rib cage or in the middle of the upper part of the abdomen (between the belly button and the end of the breastbone). Doctors do most open gallbladder surgeries after trying first to remove the gallbladder with laparoscopic surgery.
LAPAROSCOPIC SURGERY
Laparoscopic gallbladder surgery (cholecystectomy) remo ves the gallbladder and gallstones through se veral small incisions in the abdomen. The surgeon inflates your abdomen with air or carbon dioxide in order to see clearly. The surgeon inserts a lighted scope attached to a video camera (laparoscope) into one incision near the belly button. The surgeon then uses a video monitor as a guide while inserting surgical instruments into the other incisions to remove your gallbladder. Before the surgeon removes the gallbladder, you may ha ve a special X-ray procedure called intraoperative cholangiography, which shows the anatomy of the bile ducts. You will need general anesthesia for this surgery, which usually lasts 2 hours or less. After surgery, bile flows from the liver (where it is made) through the common bile duct and into the small intestine. Because the gallbladder has been removed, the body can no longer store bile between meals. In most people, this has little or no effect on digestion.
ANATOMY INVOLVED
ANATOMY INVOLVED The
gastrointestinal tract (GIT) consists of a hollow muscular tube starting from the oral cavity, where food enters the mouth, continuing through the pharynx, esophagus, stomach and intestines to the rectum and anus, where food is expelled. There are various accessory organs that assist the tract by secreting enzymes to help break down food into its component nutrients. Thus the salivary glands, liver, pancreas and gall bladder have important functions in the digestive system. Food is propelled along the length of the GIT by peristaltic movements of the muscular walls.
ANATOMY INVOLVED The
primary purpose of the gastrointestinal tract is to break food down into nutrients, which can be absorbed into the body to provide energy. First food must be ingested into the mouth to be mechanically processed and moistened. Secondly, digestion occurs mainly in the stomach and small intestine where proteins, fats and carbohydrates are chemically broken down into their basic building blocks. Smaller molecules are then absorbed across the epithelium of the small intestine and subsequently enter the circulation. The large intestine plays a key role in reabsorbing excess water. Finally, undigested material and secreted waste products are excreted from the body via defecation.
ANATOMY INVOLVED
GALL BLADDER
FUNCTIONS OF GALL BLADDER The
function of the gallbladder is to store bile and concentrate. Bile is a digestive liquid continually secreted by the liver. The bile emulsifies fats and neutralizes acids in partly digested food. A muscular valve in the common bile duct opens, and the bile flows from the gallbladder into the cystic duct, along the common bile duct, and into the duodenum (part of the small intestine).
What is Cholelithiasis and Cholecystitis?
ETIOLOGY OF DISEASE Cholelithiasis is the presence of one or more calculi (gallstones) in the gallbladder. In developed countries, about 10% of adults and 20% of people > 65 yr ha ve gallstones. Gallstones tend to be asymptomatic. The most common symptom is biliary colic; gallstones do not cause dyspepsia or fatty food intolerance. More serious complications include cholecystitis; biliary tract obstruction (from stones in the bile ducts or choledocholithiasis), sometimes with infection (cholangitis); and gallstone pancreatitis. Diagnosis is usually by ultrasonography. If cholelithiasis causes symptoms or complications, cholecystectomy is necessary.
IMAGES OF GALL STONES
RISK FACTORS
The
list of risk factors mentioned for Gallstones in various sources includes: Women between 20 and 60 years of age. They are twice more likely to develop gallstones than men. Men and women o ver age 60. Pregnant women or women who ha ve used birth control pills or estrogen replacement therapy. Native Americans. They have the highest pre valence of gallstones in the United States. A majority of Nati ve American men ha ve gallstones by age 60. Among the Pima Indians of Arizona, 70 percent of women ha ve gallstones by age 30. Mexican-American men and women of all ages. Men and women who are o verweight. People who go on "crash" diets or who lose a lot of weight quickly. Dieting Gastric bypass surgery- stomach reduction surgery Cholesterol-lowering drugs After surgery, alcohol consumption lifestyle, Less intake of protein rich foods No appropriate exercise
RISK FACTORS
Disease of the Small Intestine Crohns Disease Diabetes Sickle Cell Anemia Major Trauma Paralysis Fasting Long-term IV Nutrition Lack of Physical Activity Family History of Gallstones Medications including Fibrates, Somastatin (Octreotide), Ceftriaxone (Rocephin)
Cholecystitis is inflammation of the gallbladder, usually resulting from a gallstone blocking the cystic duct
SIGNS AND SYMPTOMS
Cholecystitis usually presents as a pain in the right upper quadrant. This is usually a constant, severe pain. The pain may be felt to 'refer' to the right flank or right scapular region at first.
This
This
may also present with the abo ve mentioned pain after eating greasy or fatty foods such as pastries, pies and fried foods. is usually accompanied by a low grade fever, vomiting and nausea.
More severe symptoms such as high fever, shock and jaundice indicate the development of complications such as abscess formation, perforation or ascending cholangitis. Another complication, gallstone ileus, occurs if the gallbladder perforates and forms a fistula with the nearby small bowel, leading to symptoms of intestinal obstruction. Chronic cholecystitis manifests with non-specific symptoms such as nausea, vague abdominal pain, belching, and diarrhea.
DIAGNOSTIC/ LAB TEST
Ultrasonography-Gallstones are suspected in patients with biliary colic. Abdominal ultrasonography is the method of choice for detecting gallbladder stones; sensiti vity and specificity are 95%. Ultrasonography also accurately detects sludge. CT SCAN MRI (Magnetic Resonance Imaging ) Oral cholecystography Hepatobiliary Nuclear Scan Endoscopic ultrasonography accurately detects small gallstones (< 3 mm) and may be needed if other tests are equivocal.
DIAGNOSTIC/ LAB TEST
Laboratory tests usually are not helpful; typically, results are normal unless complications develop. Asymptomatic gallstones and biliary sludge are often detected incidentally when imaging, usually ultrasonography, is done for other reasons. About 10 to 15% of gallstones are calcified and visible on plain x-rays. Elevated conjugated Bilirubin Elevated Alkaline Phosphatase Elevated Serum Amylase Elevated Lipase Slightly elevated White Blood Cell count
DIAGNOSTIC/ LAB TEST
THERAPEUTIC NURSING MANAGEMENT Assess the clients manifestations carefully to help determine the diagnosis. Check vital signs at regular intervals to document inflammation associated with stones. Also assess the clients knowledge of the diagnostic process. Closely monitor the client for manifestations of obstruction from gallstones.
THERAPEUTIC NURSING MANAGEMENT
Monitor fluid and electrolyte balance During an acute attack of biliary colic, the client remains on NPO status, with IV fluids administered to maintain hydration. The client may lose fluids if an NG tube has been inserted for symptomatic relief of vomiting or if pancreatitis is a probable diagnosis. The
diet progress according to the clients tolerance. The client is advised to avoid foods that precipitate biliary colic. Instructions may include avoiding a fatty meal or a large meal after fasting. Monitor for complications-monitoring for complications of gallstones disease includes observing, most commonly, for de velopment of manifestations of biliary colic. Conditions such as bile duct obstruction, cholangitis, pancreatitis, acute calculus, and cholecystitis may occur and cause manifestations consistent with gallbladder disease and subsequent sepsis and death. Clients with diabetes mellitus and gallstones are more susceptible to complications of sepsis. Because the gallbladder is left in place interventions except cholecystectomy, stone recurrence is likely.
THERAPEUTIC NURSING MANAGEMENT Nursing Activity
Encourage to drink plenty of fluids. Some patients have anecdotally reported that symptoms can be temporarily reduced by drinking se veral
glasses of water when experiencing gallstone pain. This approach will not eliminate the gallstones or improve the patient's condition in the long term.
Promote eating a balanced/nutritious diet that is low on fat. Fat in the digestive tract causes bile to be secreted, which bile comes from the gallbladder. If bile is being secreted, this can cause a calculi to get stuck in the bile duct, which is what causes the patient to have pain in the first place. Pain is acute and can last as long as 6 to 24 hours after onset. Most patients that experience a gallbladder attack end up going to the Emergency Room because the pain is so se vere.
THERAPEUTIC NURSING MANAGEMENT
Administer oral dissolution therapy: These are medicines that can melt small cholesterol gallstones. Ask your caregiver for more information about using oral dissolution therapy for cholelithiasis. Fluid/Electrolyte Management (NIC) Independent Assess for unusual bleeding, e.g., oozing from injection sites, epistaxis, bleeding gums, ecchymosis, petechiae, hematemesis/melena. Prothrombin is reduced and coagulation time prolonged Collaborative when bile flow is obstructed, increasing risk of bleeding/hemorrhage.
THERAPEUTIC NURSING MANAGEMENT
Keep
patient NPO as necessary. Insert NG tube, connect to suction, and maintain patency as Decreases GI secretions and motility. indicated. Provides rest for GI tract. Administer antiemetics, e.g., prochlorperazine (Compazine). Reduces nausea and prevents vomiting. Review laboratory studies, e.g., Hgb/Hct, electrolytes, ABGs (pH), clotting times. Aids in e valuating circulating volume, identifies deficits, and influences choice of intervention for Administer IV fluids, electrolytes, and vitamin K. replacement/correction. Maintains circulating volume and corrects imbalances.
THERAPEUTIC NURSING MANAGEMENT
Administer Pain Medications Document and record clients response to the medication. Encourage the patient to verbalize the effectiveness of the medication by describing whether the pain is absent or decreased. Provide a quiet environment and use relaxation techniques, like back rub, to promote rest. If the client still vomits, obtain order for an NG tube with a suction to relieve distention and vomiting. For the client undergoing endoscopic retrograde papillotomy or stone removal, a local anesthetic solution is sprayed at the back of the throat to facilitate the passing of the endoscope. Inform the client to avoid intake of fatty foods because this may cause biliary colic that may trigger the attack of the problem. Advise the client on what to do if another attack occurs. Provide written materials on gallbladder disease to aid the client in understanding and in making decision.
Pharmacology
COMPLICATIONS
Pain Peritonitis Pancreatitis Cholecystitis Cholangitis Pancreatitis Nausea and Vomiting Cholestasis, extrahepatic Bile Stricture
AGE RELATED CHANGES AND GERONTOLOGICAL CONSIDERATIONS
Research about the relationship
Kurtin
Department of Chemistry, Trinity University, San Antonio, TX 78212, USA.
Abstract
of age in gallstone formation
WE, Schwesinger WH, Diehl AK.
BACKGROUND: The association between pigment cholelithiasis and advancing age has been previously described but little is known about the time-course of these changes.
AIM: To
determine the specific changes that occur in the chemical composition of gallstones with increasing age.
METHODS: Gallstones
RESULTS: Forty-fi ve
were collected from 387 non-cirrhotic patients and visually classified as either cholesterol or pigment. All stones were quantitatively analyzed by Fourier transform infrared spectroscopy for cholesterol, bilirubin, carbonate and phosphate and the results correlated with stone type and patient age. patients had pigment stones (12 %) and 342 had cholesterol stones (88 %). No patient had both types. There was a reciprocal relationship between the mean cholesterol and bilirubin contents of stones over time with cholesterol accounting for 54% of the weight of gallstones before age 30 and only 17% after age 70. Similarly, the mean content (by weight) of bilirubin was 35% before age 30 but 61% after age 70. In addition, the fraction of gallstones containing carbonate or phosphate salts increased sequentially with age (6% at age 30 to 57% at age 70).
AGE RELATED CHANGES AND GERONTOLOGICAL CONSIDERATIONS
CONCLUSIONS: (1). The ratio of pigment to cholesterol gallstones increases directly with age. (2) The cholesterol content of stones steadily decreases after age 50 while the content of bilirubin, phosphate and carbonate gradually increases. (3) These data suggest that, during aging, cholesterol may become solubilized and may be replaced by calcium salts of carbonate, phosphate or bilirubinate.
PMID: 12678532 [PubMed - indexed for M EDLINE] People over age 60 are more likely to de velop gallstones than younger people. As we age, our body tends to secrete more cholesterol into bile when too much of this cholesterol builds up in bile, the extra cholesterol is not properly absorbed and, o ver time, turns into stones that may block the normal flow of bile. The cholesterol content of stones steadily decreases after age 50 while the content of bilirubin, phosphate and carbonate gradually increases. These data suggest that, during aging, cholesterol may become solubilized and may be replaced by calcium salts of carbonate, phosphate or bilirubinate. Therefore, giving us an information that after age of 50, there is a greater chance of developing pigmented gallstones then cholesterol gallstones.
PROCEDURE
Skin preparation Before operation, client is showered using antibacterial soap. Shaving of hair at the site of incision. Apply Cleansing, alcohol and antiseptic solution on the surgical site using sterile gauze
SKIN PREPARATION
Circular motion from around umbilicus
going outwards. From posterior axillary fold/line to anterior. Mid-upper thigh 4 strokes downwards. Outer to inner portion. Let it dry.
DRAPING
Waterproof
drape may be placed. 4 drapes are used. -Put drapes one at a time with folded drapes down and protect from contamination. -1st towel/drape applied to side of the one applying it.
-2nd and 3rd drape placed at superior and inferior portion of abdominal site. -4th drape at the opposite of 1 st drape. -Provide clips if necessary
POSITION
Patient will be given sedative before going to the OR.
Induction of Anesthesia
Spinal Anesthesia
Position client at C-position on his/her Right side Then,
position client on supine position for surgery.
SPINAL ANESTHESIA
Spinal anaesthesia, also called spinal analgesia or sub-arachnoid block (SAB), is a form of regional anaesthesia involving injection of a local anaesthetic into the Subarachnoid space, generally through a fine needle, usually 3.5 inches (9 cm) long. For extremely obese patients, some anaesthesiologists prefer spinal needles which are seven inches (18 cm) long. The tip of the spinal needle has a point or small bevel. Recently pencil point needles have been made available.
SPINAL ANESTHESIA
Current usage of this technique is waning in the developed world, with epidural analgesia or combined spinal-epidural anaesthesia emerging as the techniques of choice where the cost of the disposable 'kit' is not an issue. However spinal analgesia is the mainstay of anaesthesia in countries like India and parts of Africa, excluding the major centres. Thousands of spinal anaesthetics are administered daily in hospitals and nursing homes. At a low cost, a surgery of up to two hours duration can be performed. Indications: This
technique is very useful in patients having an irritable airway (bronchial asthma or allergic bronchitis), anatomical abnormalities which make endotracheal intubation very difficult (micrognathia), borderline hypertensives where administration of general anaesthesia or endotracheal intubation can further elevate the blood pressure, procedures in geriatric patients. It is the technique of choice for diabetic patients. Contraindications: Non-availability of patient's consent, local infection or sepsis at the site of lumbar puncture, bleeding disorders, space occupying lesions of the brain, disorders of the spine and maternal hypotension.
INCISION SITE Upper right abdominal region particularly right hypochondriac region
THE PROCEDURE
Open cholecystectomy is major surgery that is performed in 5% of cases (NDDIC). Most often, open cholecystectomy is performed because of complications such as perforation, infection, or adhesions from pre vious surgery, and sometimes after such complications are encountered during laparoscopy. Patients with suspect cancer, very large stones, end stage liver disease, or bleeding disorders may also require open cholecystectomy. First, a 5- to 8-inch right or midline incision is made in the abdomen, and the abdominal cavity is opened to expose the gallbladder. The artery to the gallbladder and the cystic duct leading from it are tied off and cut, and the gallbladder is removed. Before the abdomen is closed, drains may be placed under the liver and in the bile duct. The drains, which are kept in place from 4 to 10 days, are remo ved after x-ray studies show there are no more stones.
BSN 206 GROUP 22
Nur sing is not a p r ofession fo r a bette r cost b u t fo r a bette r
CAUSE
-hsd
Case study presented by Group 22 BSN 206
CLINICAL VIEW Ever wonder whom, when, where, what surgery was before? How was it evolved? At present, surgery is a medical specialty that uses operative manual and in insstru rum mental techniq iqu ues on a patie ien nt to investigate
and/or treat a pathological condition such as disease or injury, to help improve bodily function or appearance, and sometimes for religious reasons. Surgery originated from the Latin word chirurgia or in Greek word ch chei eir r and er erg gon whi hich ch mea eans ns ha hand nd work rk.. As sur urg ger ery y was de defi fine ned d as hand work in early times, it was done through trepanation or the drilling a hole into the skull in which earlier beliefs it would treat health problems related to intracranial pressure and other diseases in which evid iden encces suggested those who had undergone trephining had survived. As inven enti tion onss of sc scie ien nti tissts con onti tinu nuou ousl sly y evolving aft fter er yea earrs and yea earrs, we have now di diff ffer eren entt con onsi side derrati tion onss pr prio iorr to th the e pr proc oced edu ure li lik ke th the e pr prin inci cipl ple e of aseptic technique. Every in ind divid idu ual alive today, the highest as well as the lo low wes est, t, is de deri rived in an un unbr bro oken li line ne fr fro om th the e fi firrst and lo low wes estt form rms. s.
CLINICAL VIEW Ever wonder whom, when, where, what surgery was before? How was it evolved? At present, surgery is a medical specialty that uses operative manual and in insstru rum mental techniq iqu ues on a patie ien nt to investigate
and/or treat a pathological condition such as disease or injury, to help improve bodily function or appearance, and sometimes for religious reasons. Surgery originated from the Latin word chirurgia or in Greek word ch chei eir r and er erg gon whi hich ch mea eans ns ha hand nd work rk.. As sur urg ger ery y was de defi fine ned d as hand work in early times, it was done through trepanation or the drilling a hole into the skull in which earlier beliefs it would treat health problems related to intracranial pressure and other diseases in which evid iden encces suggested those who had undergone trephining had survived. As inven enti tion onss of sc scie ien nti tissts con onti tinu nuou ousl sly y evolving aft fter er yea earrs and yea earrs, we have now di diff ffer eren entt con onsi side derrati tion onss pr prio iorr to th the e pr proc oced edu ure li lik ke th the e pr prin inci cipl ple e of aseptic technique. Every in ind divid idu ual alive today, the highest as well as the lo low wes est, t, is de deri rived in an un unbr bro oken li line ne fr fro om th the e fi firrst and lo low wes estt form rms. s.
CLINICAL VIEW Ther ere e
are nu num merous sur urg gic ica al pr pro oced edur ures es in our ti tim mes es.. Our group was able to ass ssis istt in unusual sur urg gical procedure which was cholec ecy ystectomy. Cholecystectomy is the surgical procedure done to remove the gall bla ladd dder er fr fro om wh whic ich h it may be in infl flam amed ed,, in inffec ectted ed,, or obs bstr truc uctted by a stone ne.. We focused our study on two diseases associated with the gall bladder. These are cholelithiasis and cholecystitis. Both terms might sound the same and associated with the gall bladder but does not mean the same disease process. Cholelithiasis is the presence of gallstones in the gall blad bl adde derr, wh whil ile, e, ch chol olec ecy ysti titi tiss is th the e in infl flam amm mati tio on of th the e gal allb lbla ladd dder er,, us usua uall lly y resu re sult ltin ing g fr from om a gal alls lstton one e bl blo ock ckin ing g th the e cy cyssti ticc du duct ct.. As de defi fine ned, d, ch chol olec ecy yst stit itis is may have an incidence of occurring when a person has cholethiasis in which its gallstones would obstruct that causes inflammation. Both dis ise eases have similarities and differences on the signs and symptoms dep epen end ding on its condit itiion. As this cas ase e study will be disc scu uss ssed ed,, a detailed explanatio ion n on the diseas ase e process and its interventions done to remove the cause of the disease. Also what would be the nursing management when havin ing g a sur urg gic ica al cas ase e of ch cho ole lecy cysstec ecttomy pr preo eop peratively and postoperatively.
CLINICAL VIEW One of our concepts on gastrointestinal metabolism was able to associate in our related learning experience, surgery conce cep pt which was chole lecy cysstectomy. Through the experience the group had, it helped us entirely visualize and know by heart how the surgical procedure was done; what to do and to what be aware of. Though the group had a problem with surgery skills laboratory, the combined theoretical and actual procedure in the area, gave knowledge and skill that made it handy to be prepared on other procedures that might be handling in the next cases. You just don't luck into things as much as you'd like to think you do. You build step by step, whether it's frien fri endsh dship ipss or op oppo portu rtunit nities. ies.
ANATOMY/STRUCTURE/ FUNCTION Cholecystectomy
is the surgical removal of the gallbladder. It is the most common method for treating symptomatic gallstones. Surgical options include the standard procedure, called laparoscopic cholecystectomy, and an older more invasive procedure, called open cholecystectomy.
OPEN CHOLECYSTECTOMY
In open gallbladder surgery (cholecystectomy), the surgeon removes the gallbladder through a single, large incision in the abdomen. You will need general anesthesia, and the surgery lasts 1 to 2 hours. The surgeon will make the incision either under the border of the right rib cage or in the middle of the upper part of the abdomen (between the belly button and the end of the breastbone). Doctors do most open gallbladder surgeries after trying first to remove the gallbladder with laparoscopic surgery.
LAPAROSCOPIC SURGERY
Laparoscopic gallbladder surgery (cholecystectomy) remo ves the gallbladder and gallstones through se veral small incisions in the abdomen. The surgeon inflates your abdomen with air or carbon dioxide in order to see clearly. The surgeon inserts a lighted scope attached to a video camera (laparoscope) into one incision near the belly button. The surgeon then uses a video monitor as a guide while inserting surgical instruments into the other incisions to remove your gallbladder. Before the surgeon removes the gallbladder, you may ha ve a special X-ray procedure called intraoperative cholangiography, which shows the anatomy of the bile ducts. You will need general anesthesia for this surgery, which usually lasts 2 hours or less. After surgery, bile flows from the liver (where it is made) through the common bile duct and into the small intestine. Because the gallbladder has been removed, the body can no longer store bile between meals. In most people, this has little or no effect on digestion.
ANATOMY INVOLVED
ANATOMY INVOLVED The
gastrointestinal tract (GIT) consists of a hollow muscular tube starting from the oral cavity, where food enters the mouth, continuing through the pharynx, esophagus, stomach and intestines to the rectum and anus, where food is expelled. There are various accessory organs that assist the tract by secreting enzymes to help break down food into its component nutrients. Thus the salivary glands, liver, pancreas and gall bladder have important functions in the digestive system. Food is propelled along the length of the GIT by peristaltic movements of the muscular walls.
ANATOMY INVOLVED The
primary purpose of the gastrointestinal tract is to break food down into nutrients, which can be absorbed into the body to provide energy. First food must be ingested into the mouth to be mechanically processed and moistened. Secondly, digestion occurs mainly in the stomach and small intestine where proteins, fats and carbohydrates are chemically broken down into their basic building blocks. Smaller molecules are then absorbed across the epithelium of the small intestine and subsequently enter the circulation. The large intestine plays a key role in reabsorbing excess water. Finally, undigested material and secreted waste products are excreted from the body via defecation.
ANATOMY INVOLVED
GALL BLADDER
FUNCTIONS OF GALL BLADDER The
function of the gallbladder is to store bile and concentrate. Bile is a digestive liquid continually secreted by the liver. The bile emulsifies fats and neutralizes acids in partly digested food. A muscular valve in the common bile duct opens, and the bile flows from the gallbladder into the cystic duct, along the common bile duct, and into the duodenum (part of the small intestine).
What is Cholelithiasis and Cholecystitis?
ETIOLOGY OF DISEASE Cholelithiasis is the presence of one or more calculi (gallstones) in the gallbladder. In developed countries, about 10% of adults and 20% of people > 65 yr ha ve gallstones. Gallstones tend to be asymptomatic. The most common symptom is biliary colic; gallstones do not cause dyspepsia or fatty food intolerance. More serious complications include cholecystitis; biliary tract obstruction (from stones in the bile ducts or choledocholithiasis), sometimes with infection (cholangitis); and gallstone pancreatitis. Diagnosis is usually by ultrasonography. If cholelithiasis causes symptoms or complications, cholecystectomy is necessary.
IMAGES OF GALL STONES
RISK FACTORS
The
list of risk factors mentioned for Gallstones in various sources includes: Women between 20 and 60 years of age. They are twice more likely to develop gallstones than men. Men and women o ver age 60. Pregnant women or women who ha ve used birth control pills or estrogen replacement therapy. Native Americans. They have the highest pre valence of gallstones in the United States. A majority of Nati ve American men ha ve gallstones by age 60. Among the Pima Indians of Arizona, 70 percent of women ha ve gallstones by age 30. Mexican-American men and women of all ages. Men and women who are o verweight. People who go on "crash" diets or who lose a lot of weight quickly. Dieting Gastric bypass surgery- stomach reduction surgery Cholesterol-lowering drugs After surgery, alcohol consumption lifestyle, Less intake of protein rich foods No appropriate exercise
RISK FACTORS
Disease of the Small Intestine Crohns Disease Diabetes Sickle Cell Anemia Major Trauma Paralysis Fasting Long-term IV Nutrition Lack of Physical Activity Family History of Gallstones Medications including Fibrates, Somastatin (Octreotide), Ceftriaxone (Rocephin)
Cholecystitis is inflammation of the gallbladder, usually resulting from a gallstone blocking the cystic duct
SIGNS AND SYMPTOMS
Cholecystitis usually presents as a pain in the right upper quadrant. This is usually a constant, severe pain. The pain may be felt to 'refer' to the right flank or right scapular region at first.
This
This
may also present with the abo ve mentioned pain after eating greasy or fatty foods such as pastries, pies and fried foods. is usually accompanied by a low grade fever, vomiting and nausea.
More severe symptoms such as high fever, shock and jaundice indicate the development of complications such as abscess formation, perforation or ascending cholangitis. Another complication, gallstone ileus, occurs if the gallbladder perforates and forms a fistula with the nearby small bowel, leading to symptoms of intestinal obstruction. Chronic cholecystitis manifests with non-specific symptoms such as nausea, vague abdominal pain, belching, and diarrhea.
DIAGNOSTIC/ LAB TEST
Ultrasonography-Gallstones are suspected in patients with biliary colic. Abdominal ultrasonography is the method of choice for detecting gallbladder stones; sensiti vity and specificity are 95%. Ultrasonography also accurately detects sludge. CT SCAN MRI (Magnetic Resonance Imaging ) Oral cholecystography Hepatobiliary Nuclear Scan Endoscopic ultrasonography accurately detects small gallstones (< 3 mm) and may be needed if other tests are equivocal.
DIAGNOSTIC/ LAB TEST
Laboratory tests usually are not helpful; typically, results are normal unless complications develop. Asymptomatic gallstones and biliary sludge are often detected incidentally when imaging, usually ultrasonography, is done for other reasons. About 10 to 15% of gallstones are calcified and visible on plain x-rays. Elevated conjugated Bilirubin Elevated Alkaline Phosphatase Elevated Serum Amylase Elevated Lipase Slightly elevated White Blood Cell count
DIAGNOSTIC/ LAB TEST
THERAPEUTIC NURSING MANAGEMENT Assess the clients manifestations carefully to help determine the diagnosis. Check vital signs at regular intervals to document inflammation associated with stones. Also assess the clients knowledge of the diagnostic process. Closely monitor the client for manifestations of obstruction from gallstones.
THERAPEUTIC NURSING MANAGEMENT
Monitor fluid and electrolyte balance During an acute attack of biliary colic, the client remains on NPO status, with IV fluids administered to maintain hydration. The client may lose fluids if an NG tube has been inserted for symptomatic relief of vomiting or if pancreatitis is a probable diagnosis. The
diet progress according to the clients tolerance. The client is advised to avoid foods that precipitate biliary colic. Instructions may include avoiding a fatty meal or a large meal after fasting. Monitor for complications-monitoring for complications of gallstones disease includes observing, most commonly, for de velopment of manifestations of biliary colic. Conditions such as bile duct obstruction, cholangitis, pancreatitis, acute calculus, and cholecystitis may occur and cause manifestations consistent with gallbladder disease and subsequent sepsis and death. Clients with diabetes mellitus and gallstones are more susceptible to complications of sepsis. Because the gallbladder is left in place interventions except cholecystectomy, stone recurrence is likely.
THERAPEUTIC NURSING MANAGEMENT Nursing Activity
Encourage to drink plenty of fluids. Some patients have anecdotally reported that symptoms can be temporarily reduced by drinking se veral
glasses of water when experiencing gallstone pain. This approach will not eliminate the gallstones or improve the patient's condition in the long term.
Promote eating a balanced/nutritious diet that is low on fat. Fat in the digestive tract causes bile to be secreted, which bile comes from the gallbladder. If bile is being secreted, this can cause a calculi to get stuck in the bile duct, which is what causes the patient to have pain in the first place. Pain is acute and can last as long as 6 to 24 hours after onset. Most patients that experience a gallbladder attack end up going to the Emergency Room because the pain is so se vere.
THERAPEUTIC NURSING MANAGEMENT
Administer oral dissolution therapy: These are medicines that can melt small cholesterol gallstones. Ask your caregiver for more information about using oral dissolution therapy for cholelithiasis. Fluid/Electrolyte Management (NIC) Independent Assess for unusual bleeding, e.g., oozing from injection sites, epistaxis, bleeding gums, ecchymosis, petechiae, hematemesis/melena. Prothrombin is reduced and coagulation time prolonged Collaborative when bile flow is obstructed, increasing risk of bleeding/hemorrhage.
THERAPEUTIC NURSING MANAGEMENT
Keep
patient NPO as necessary. Insert NG tube, connect to suction, and maintain patency as Decreases GI secretions and motility. indicated. Provides rest for GI tract. Administer antiemetics, e.g., prochlorperazine (Compazine). Reduces nausea and prevents vomiting. Review laboratory studies, e.g., Hgb/Hct, electrolytes, ABGs (pH), clotting times. Aids in e valuating circulating volume, identifies deficits, and influences choice of intervention for Administer IV fluids, electrolytes, and vitamin K. replacement/correction. Maintains circulating volume and corrects imbalances.
THERAPEUTIC NURSING MANAGEMENT
Administer Pain Medications Document and record clients response to the medication. Encourage the patient to verbalize the effectiveness of the medication by describing whether the pain is absent or decreased. Provide a quiet environment and use relaxation techniques, like back rub, to promote rest. If the client still vomits, obtain order for an NG tube with a suction to relieve distention and vomiting. For the client undergoing endoscopic retrograde papillotomy or stone removal, a local anesthetic solution is sprayed at the back of the throat to facilitate the passing of the endoscope. Inform the client to avoid intake of fatty foods because this may cause biliary colic that may trigger the attack of the problem. Advise the client on what to do if another attack occurs. Provide written materials on gallbladder disease to aid the client in understanding and in making decision.
Pharmacology
COMPLICATIONS
Pain Peritonitis Pancreatitis Cholecystitis Cholangitis Pancreatitis Nausea and Vomiting Cholestasis, extrahepatic Bile Stricture
AGE RELATED CHANGES AND GERONTOLOGICAL CONSIDERATIONS
Research about the relationship
Kurtin
Department of Chemistry, Trinity University, San Antonio, TX 78212, USA.
Abstract
of age in gallstone formation
WE, Schwesinger WH, Diehl AK.
BACKGROUND: The association between pigment cholelithiasis and advancing age has been previously described but little is known about the time-course of these changes.
AIM: To
determine the specific changes that occur in the chemical composition of gallstones with increasing age.
METHODS: Gallstones
RESULTS: Forty-fi ve
were collected from 387 non-cirrhotic patients and visually classified as either cholesterol or pigment. All stones were quantitatively analyzed by Fourier transform infrared spectroscopy for cholesterol, bilirubin, carbonate and phosphate and the results correlated with stone type and patient age. patients had pigment stones (12 %) and 342 had cholesterol stones (88 %). No patient had both types. There was a reciprocal relationship between the mean cholesterol and bilirubin contents of stones over time with cholesterol accounting for 54% of the weight of gallstones before age 30 and only 17% after age 70. Similarly, the mean content (by weight) of bilirubin was 35% before age 30 but 61% after age 70. In addition, the fraction of gallstones containing carbonate or phosphate salts increased sequentially with age (6% at age 30 to 57% at age 70).
AGE RELATED CHANGES AND GERONTOLOGICAL CONSIDERATIONS
CONCLUSIONS: (1). The ratio of pigment to cholesterol gallstones increases directly with age. (2) The cholesterol content of stones steadily decreases after age 50 while the content of bilirubin, phosphate and carbonate gradually increases. (3) These data suggest that, during aging, cholesterol may become solubilized and may be replaced by calcium salts of carbonate, phosphate or bilirubinate.
PMID: 12678532 [PubMed - indexed for M EDLINE] People over age 60 are more likely to de velop gallstones than younger people. As we age, our body tends to secrete more cholesterol into bile when too much of this cholesterol builds up in bile, the extra cholesterol is not properly absorbed and, o ver time, turns into stones that may block the normal flow of bile. The cholesterol content of stones steadily decreases after age 50 while the content of bilirubin, phosphate and carbonate gradually increases. These data suggest that, during aging, cholesterol may become solubilized and may be replaced by calcium salts of carbonate, phosphate or bilirubinate. Therefore, giving us an information that after age of 50, there is a greater chance of developing pigmented gallstones then cholesterol gallstones.
PROCEDURE
Skin preparation Before operation, client is showered using antibacterial soap. Shaving of hair at the site of incision. Apply Cleansing, alcohol and antiseptic solution on the surgical site using sterile gauze
SKIN PREPARATION
Circular motion from around umbilicus
going outwards. From posterior axillary fold/line to anterior. Mid-upper thigh 4 strokes downwards. Outer to inner portion. Let it dry.
DRAPING
Waterproof
drape may be placed. 4 drapes are used. -Put drapes one at a time with folded drapes down and protect from contamination. -1st towel/drape applied to side of the one applying it.
-2nd and 3rd drape placed at superior and inferior portion of abdominal site. -4th drape at the opposite of 1 st drape. -Provide clips if necessary
POSITION
Patient will be given sedative before going to the OR.
Induction of Anesthesia
Spinal Anesthesia
Position client at C-position on his/her Right side Then,
position client on supine position for surgery.
SPINAL ANESTHESIA
Spinal anaesthesia, also called spinal analgesia or sub-arachnoid block (SAB), is a form of regional anaesthesia involving injection of a local anaesthetic into the Subarachnoid space, generally through a fine needle, usually 3.5 inches (9 cm) long. For extremely obese patients, some anaesthesiologists prefer spinal needles which are seven inches (18 cm) long. The tip of the spinal needle has a point or small bevel. Recently pencil point needles have been made available.
SPINAL ANESTHESIA
Current usage of this technique is waning in the developed world, with epidural analgesia or combined spinal-epidural anaesthesia emerging as the techniques of choice where the cost of the disposable 'kit' is not an issue. However spinal analgesia is the mainstay of anaesthesia in countries like India and parts of Africa, excluding the major centres. Thousands of spinal anaesthetics are administered daily in hospitals and nursing homes. At a low cost, a surgery of up to two hours duration can be performed. Indications: This
technique is very useful in patients having an irritable airway (bronchial asthma or allergic bronchitis), anatomical abnormalities which make endotracheal intubation very difficult (micrognathia), borderline hypertensives where administration of general anaesthesia or endotracheal intubation can further elevate the blood pressure, procedures in geriatric patients. It is the technique of choice for diabetic patients. Contraindications: Non-availability of patient's consent, local infection or sepsis at the site of lumbar puncture, bleeding disorders, space occupying lesions of the brain, disorders of the spine and maternal hypotension.
INCISION SITE Upper right abdominal region particularly right hypochondriac region
THE PROCEDURE
Open cholecystectomy is major surgery that is performed in 5% of cases (NDDIC). Most often, open cholecystectomy is performed because of complications such as perforation, infection, or adhesions from pre vious surgery, and sometimes after such complications are encountered during laparoscopy. Patients with suspect cancer, very large stones, end stage liver disease, or bleeding disorders may also require open cholecystectomy. First, a 5- to 8-inch right or midline incision is made in the abdomen, and the abdominal cavity is opened to expose the gallbladder. The artery to the gallbladder and the cystic duct leading from it are tied off and cut, and the gallbladder is removed. Before the abdomen is closed, drains may be placed under the liver and in the bile duct. The drains, which are kept in place from 4 to 10 days, are remo ved after x-ray studies show there are no more stones.
BSN 206 GROUP 22
Nur sing is not a p r ofession fo r a bette r cost b u t fo r a bette r
CAUSE
-hsd
