1. Cholecystitis/choleiithiasis: inflammation of gallbladder due to bacterial infection, presence of cholelithiasis (stones, cholesterol, calcium, or bile in the gallbladder), or choledocholithiasis (stone in the common bile duct) and/or obstruction. Acute cholecystitis is abrupt in onset, but the patient usually has a history of several attacks of fatty-food intolerance. Patient with chronic cholecystitis has a history of several attacks of moderate severity and has usually learned to avoid fatty foods to decrease symptoms.
    1. Pathophysiology: calculi from increased concentration of bile salts, pigments, or cholesterol due to metabolic or hemolytic disorders, biliary stasis-precipitation of salts into stones, or inflammation causing bile constituents to become altered.
    2. Risk factors:
      1. Womanhood.
      2. Obesity.
      3. Pregnancy or previous pregnancies.
      4. Use of birth control pills or hormone replacement therapy.
      5. High-fat, low-fiber diets.
      6. Rapid weight loss.
      7. History of Crohns disease.
      8. Genetics.
      9. Age: increased risk over 40.
      10. Certain drugs to lower lipids; clofibrate (Atromid-S).
      11. Other diseases: cirrhosis of liver.
    3. Assessment:
      1. Subjective data:
        1. Pain:
          1. Type-severe colic, radiating to the back under the scapula and to the right shoulder.
          2. Positive Murphy's sign-a sign of gallbladder disease consisting of pain on taking a deep breath when pressure is placed over the location of the gallbladder.
          3. Location-right upper quadrant, epigastric area, flank.
          4. Duration-spasm of duct attempting to dislodge stone lasts until dislodged or relieved by medication, or sometimes by vomiting.
        2. GI-anorexia, nausea, feeling of fullness, indigestion, intolerance of fatty foods.
      2. Objective data:
        1. GI-belching, vomiting, clay-colored stools.
        2. Vital signs-increased pulse, fever.
        3. Skin-chills, jaundice.
        4. Urine-dark amber.
        5. Lab data-elevated:
          1. WBC.
          2. Alkaline phosphatase.
          3. Serum amylase, lipase.
          4. AST (SGOT).
          5. Bilirubin.
        6. Diagnostic studies:
          1. Ultrasound.
          2. Cholangiography.
          3. Computed tomography (CT) scan.
          4. Endoscopic retrograde cholangiopancreatography (ERCP).
    4. Analysis/nursing diagnosis:
      1. Pain related to obstruction of bile duct due to
      2. cholelithiasis.
      3. Altered nutrition, more than body requirements, related to ingestion of fatty foods.
      4. Altered nutrition, less than body requirements, related to hesitancy to eat due to anorexia and nausea.
      5. Risk for fluid volume deficit related to episodes of vomiting.
      6. Knowledge deficit related to dietary restrictions.
    5. Nursing care plan/implementation:
      1. Nonsurgical interventions:
        1. Goal: promote comfort.
          1. Medications as ordered: meperidine, antibiotics, antispasmodics, electrolytes.
          2. Avoid morphine due to spasmodic effect.
          3. NG tube to low suction.
          4. Diet: fat free when able to tolerate food.
          5. Lithotripsy: gallstones fragmented by shock waves
          6. Oral dissolution therapy: ursodeoxycholic acid (ursodiol [Actigall]).
        2. Goal: health teaching:
          1. Signs, symptoms, and complications of disease.
          2. Fat-free diet.
          3. Desired effects and side effects of prescribed medications.
          4. Prepare for possible removal of gallbladder (cholecystectomy) if conservative treatment unsuccessful.
      2. Surgical interventions:
        1. Preoperative-Goal: prevent injury:
        2. Postoperative-Goal: promote comfort
          1. Laparoscopic laser cholecystectomy- tiny incisions/puncture wounds; gallbladder is removed using a videoguided system with a camera; patient is discharged that day or next day, able to resume normal diet and work activities in a few days.
          2. Endoscopic retrograde cholangiopancreatography (ERCP) with papillotomy-removes stones from bile duct. No incision; done under sedation, not anesthesia.
          3. Open-incision cholecystectomy.
            1. Promote tube drainage:
              1. NG tube to low suction.
              2. T-tube to closed-gravity drainage, to preserve patency of edematous common duct and ensure bile drainage; usual amount 500-1000 mL/24 hr; dark brown drainage.
              3. Provide enough tubing to allow turning without tension.
              4. Empty and record bile drainage q8h.
            2. Position: low Fowlers to semiFowler's to facilitate T-tube drainage.
            3. Dressing: dry to protect skin (because bile excoriates skin).
            4. Clamp T-tube as ordered.
              1. Observe for abdominal distention, pain, nausea, chills, or fever.
              2. Unclamp tube and notify MD if symptoms appear.
        3. Goal: prevent complications.
          1. IV fluids with vitamins.
          2. Cough, turn, and deep breathe with open incision, particularly with removal of gall bladder (prone to respiratory complication because of high incision).
          3. Early ambulation to prevent vascular complications and aid in expelling flatus.
          4. Monitor for jaundice: skin, sclera, urine, stools.
          5. Monitor for signs of hemorrhage, infection.
        4. Goal: health teaching.
          1. Diet: fat free for 6 weeks.
          2. Signs of complications of food intolerance, pain, infection, hemorrhage.
    6. Evaluation/outcome criteria:
      1. No complications.
      2. Able to tolerate food.
      3. Plans follow-up care.
      4. Possible weight reduction.