Introduction
Cholelithiasis occurs when gall stones obstruct the cystic duct resulting in discomfort (Tanya & Sara, 2011). Its prevalence is associated with increased consumption of high-fat meals. Cholecystitis on the other hand refers to gall bladder inflammation which results in the development of gall stones (Tanya & Sara, 2011). Generally, the two conditions are associated. Often an operation known as cholecystectomy is performed to reverse the condition.
Cholecystectomy involves excising of the gall bladder from the posterior liver wall and ligation of the cystic duct, vein as well as and artery. Usually, the performing surgeon approaches the gall bladder via the right upper paramedian or in some instances via the upper midline incision if appropriate.
In instances where there is a suspected presence of stones in the common duct, the cholangiographic operation may be undertaken. In instances where pathologic actions have dilated the common duct, the performing surgeon may further dilate the duct to facilitate the removal of the stones. A thin instrument is passed into the duct to collect the stones.
The stones are collected either as a whole piece or after being crushed into pieces as deemed appropriate. Usually, after exploration of the common duct, a T-tube is inserted by the surgeon to ensure that there is an adequate bile drainage mechanism during the healing process (Ibrahim et al., 2006). The tube also avails a route for post-operative cholangiography when such is necessary.
Often when laparoscopic cholecystectomy fails to provide for stone retrieval, traditional open cholecystectomy is applied. The same is also undertaken when a patient’s physique does not provide room for gall bladder access (Tanya & Sara, 2011). This is common with obese clients (Guerriero, 2008).
Adults with small frames also present problems in gall bladder accessibility and hence the need for conventional open cholecystectomy. Mostly this procedure is performed through laparoscopic incisions using a laser (Tacchino, Greco, & Matera, 2010; Tian et al., 2009). Most patients, however, prefer the conventional open cholecystectomy due to its acute symptomatology and avoidance of future stone presence recurrence.
Care setting
The care setting for after cholecystectomy operation is normally planned on a short-term basis. However, when complications arise including emphysema, gangrene, or perforation, in-patient stay may be appropriately indicated. Among the concern areas on admission include cholecystitis with cholelithiasis, pancreatitis, peritonitis, psychological care perspective, and possible surgical intervention (Tajima & Katagiri, 2009). Discharge planning is also necessary whereby several concerns are dressed including possible assistance with wounds and other homemaker tasks.
The nursing priorities will however include;
- Respiratory functionality enhancement
- Complications prevention
- Information dissemination about the condition including procedures, prognosis, and treatment necessities.
Discharge goals
Nursing care will focus on achieving specific goals t the time of discharging the patient. These will include;
- Adequate ventilation/oxygenation to meet the patient’s needs/requirements
- Minimizing/preventing possible complications (Pardo-Mindan et al., 2008).
- Sufficient information available on the disease process, surgical procedures, prognosis, and the adopted therapeutic regime (Syrakos, 2007).
- After discharge care plan.
Nursing Diagnosis
Various diagnoses are evaluated to establish the best possible approach in the patient’s treatment for the mentioned condition (Lukovich, Vanca, & Gero, 2009). Possible diagnoses for this case are discussed below and justification provided.
Nursing Diagnosis 1: Pain, Acute
Pain is related to biologically injuring agents like obstruction in the duct, inflammations, and tissue ischemia/neurosis. It is evidenced by patient reporting of pain, biliary colic, facial pain mask, as well as autonomic responses like change in blood pressure and pulse (Joris et al., 2007). The desired outcomes in pain management include patient reports of pain relief and demonstration of relaxation position as evidenced by patient’s activities.
Actions/Interventions
Managing pain takes either an independent or collaborative form. Independent pain management begins with observing and documenting the location of the pain. Pain is ranked based on the severity on a scale of 0-10 (Joris et al., 2007). The character of pain is also documented, for instance, if it is steady, intermittent, or colicky. After administration of pain killers, the patient is observed for responses and a report generated on the same. Additionally, the patient is encouraged to have bed rest and assume a comfortable position (Joris et al., 2007). The temperature of the environment is also regulated.
Rationale
Assessment and ranking of pain help in differentiation of the causes of pain and hence avail relevant information on progressions of disease, possible complication, and effectiveness of other measures of intervention put in place. Severe pain, for instance, indicates the development of further complications (Joris et al., 2007). Bed rest in low-Fowler’s position decreases intra-abdominal pressure. However, a patient is always let to assume the position with the least pain. Control the environmental conditions helps in the reduction of itchiness and skin dryness. Further, it limits dermal discomfort experienced by the patient.
Other than these independent pain management measures, collaborative measures include maintenance of status and insertion/maintenance of NG suction. Additionally, pain management drugs are administered as indicated. Such drugs include Anticholinergics like atropine and propantheline (Pro-Banthı-one) as well as sedatives like Phenobarbital. Narcotics are also administered including meperidine hydrochloride (Demerol) and morphine sulfate. Other drugs include Smooth muscle relaxants, for instance, papaverine (Pavabid) and amyl nitrite. Antibiotics are also administered.
Rationale
While anti-biotic are meant to eliminate infections and hence inflammation, most of the mentioned drugs are meant to directly relieve the patient from pain.
Nursing Diagnosis 2: Breathing pattern
This is often associated with pain, muscular impairment, reduced levels of energy, and the presence of fatigue (Vagenas et al., 2006). It is evidenced by changes in respiratory depth, lowered vital capacity as well as holding breath amounting to reluctance to cough (Tajima & Katagiri, 2009).
The desired outcomes will aim to establish an effective pattern of breathing on the patient. The patients will be monitored to avoid any signs of respiratory complications which may compromise his/her health.
Actions/interventions
These will include measures put in place to assess the patient’s health changes throughout admission. They include;
Respiratory monitoring
This may be done either independently or collaboratively as appropriate. Independent respiratory monitoring involves the following;
Monitoring and evaluating the rate and depth of respiration
Rationale:
Shallow breathing levels, respirations accompanied with splinting and holding of breathing often cause hypoventilation to require constant evaluation and monitoring to keep the patients breathing in check (Andrew, 2009).
Auscultate breath sounds
Rationale:
Possible atelectasis is suggested by areas with reduced/absence of breath sounds (Andrew, 2009). Adventitious sounds on the other hand suggest possible congestions.
Assisting patients in turning, as well as coughing and periodical deep breathing. Patients are also shown how to splint incision and given instructions on how to develop effective breathing patterns
Rationale:
These processes assist the ventilation of various lung segments and also improve mobilization alongside expectoration secretions.
Bead head elevation and maintenance of low Fowler position. When coughing or ambulating, the patient’s abdomen is provided with support
The measures facilitate the expansion of the lungs. Splinting provides for incisional support and in turn reduces tension exhibited by muscles (Pardo-Mindan et al., 2008). This promotes cooperation with the therapeutic regime being administered.
Collaborative measures in monitoring respiratory activities include;
Availing of assistive apparatus e.g. the incentive spirometer
Rationale:
It assists in the optimization of expansion of the lungs and hence offers a solution for atelectasis.
Analgesics are administered before availing of treatments for breathing as well as therapy sessions
Rationale:
This process enhances patient coughing capability as well as deep breathing.
Nursing diagnosis 3: Fluid volume, risk of deficiency
Possible associated risk factors, in this case, include losses resulting from NG aspiration, vomiting, restricted medical intake, and changed coagulation like declined prothrombin, reduced coagulation duration (Andrew, 2009).
On basis of the diagnosis, it is desired that the patient display sufficient fluid balance, the mucus membrane should be moist, skin turgor and urine output should be normal (Hong &, You, 2009).
Actions/intervention measures
Independent measures in this case are also classified as either independent or collaborative. Independent measures include the following;
Monitoring of I/0, including NG tube drainage, T-tube, and wound conditions. The patient is also weighed periodically to monitor changes
Rationale:
Information regarding replacement needs and organ capability are availed. The initial output of bile drainage should lie approximately between 200ml and 500ml (Candela, 2007). This is output through the T-tube. However, this value is expected to gradually reduce (Andrew, 2009). Large bile amounts indicate the presence of unresolved obstruction issues or biliary fistula.
Vital signs monitoring like membrane condition, peripheral pulse values, and capillary refill are necessary.
Rationale:
They act as indicators of circulation volume inadequacies.
Observation of bleeding signs
Rationale:
It enhances prothrombin reduction and prolongs coagulation duration in instances where bile flow is obstructed resulting in increased vulnerability to bleeding risks (Zhi et al., 2007).
Injections are administered using small gauge syringes and after venipuncture, the pressure applied takes a longer duration than it often does
Rationale:
This facilitates reduced trauma as well as bleeding/hematoma risks.
Patients are made to use cotton swabs and mouthwash in place of conventional brushing using toothpaste
Rationale:
This brings about a decline in gum bleeding.
Collaborative measures include the following;
Laboratory investigations monitor including Hb/Hct, electrolytes, prothrombin level/clotting time evaluation.
Rationale:
Offer relevant information on circulation volume flows, body electrolyte balance, and clotting factors adequacy.
Administration of IV fluids as well as blood products
Rationale:
This assists in the maintenance of sufficient circulation volume and assists in the replacement of clotting factors. The electrolytes aid in the correction of body imbalances de to excessive gastric and wound losses (Jacques et al., 2007). Vitamin K assists in the replacement of factors that facilitate the clotting process.
Nursing diagnosis 4: Skin/Tissue integrity and impairment
These are related to chemical substances e.g. bile, secretions stasis, altered state of nutrition as well as metabolic state and body structure invasion as a result of T-tubes insertion. It is evidenced by skin/subcutaneous tissue disruption (Jacques et al., 2007). The desirable nursing outcomes include healing of the wound without complications, demonstration of behaviors that enhance healing and also bar skin from breaking down.
Actions/interventions
Independent interventions include:
Observation of the color and another characteristic of drainage
Rationale:
During the initial stages, drainage contains bloodstains. This is expected to change to greenish-brown within a few hours.
Frequent changing of wound dressing and cleaning of the same using soap and water. Sterile petroleum jelly is applied to the wound.
Rationale:
These measures are useful in keeping the skin hygienically clean and hence protect it from excoriation.
Application of Montgomery straps
Rationale:
This measure facilitates regular dressing alterations and hence reduced the possibility of skin trauma (Tan et al., 2006).
Other independent intervention measures include the usage of disposable ostomy bags, placement in low fowler position, monitoring of the puncture sites, and checking of the T-tube and incisional drains to ensure continuous free flow (Jacques et al., 2007; Ji, 2006). Additionally, the T-tube is maintained in a closed circulation.
While ostomy appliances assist in the collection of large volumes of drainage for more accurate analysis, fowler’s position is adopted to facilitate bile drainage without complication. Areas of bleeding also need constant monitoring to avoid the possibility of unwanted bleeding (Jacques et al., 2007). Constant checking of the T-tube ensures that it remains in the duct to collect the stones being removed from the system (Witzke & Gagliardi, 2007).
Proper position of the aforementioned ensures that no unwanted substances accumulate in the operative area (Miguel, Frits, & Alexander, 2009). Additionally, maintaining the T-tube in closed systems of collection lowers contamination risk in addition to preventing cases of skin irritation (Ros & Carlsson, 2009).
Collaborative measures in wound care on the other hand include administration of antibiotics, clamping of the T-tube per schedule, regular surgical intervention measures, and monitoring of laboratory evaluations. Antibiotics are necessary for the treatment of cases of possible infection (Jacques et al., 2007).
Clamping of T-tube on the other hand allows testing of the common bile duct patency before removal of the tube (Tanya & Sara, 2011). A necessity may arise for drainage of blocked ducts or fistulectomy as a measure for treating abscess and mending of fistula. Laboratory results help detect cases of leukocytosis which show inflammatory processes for instance formation of abscess and pancreatitis development.
Nursing Diagnosis 5: Knowledge deficiency about the condition, prognosis, treatment, individual care, and needs after discharge
This is mainly a factor of lack of exposure, misinterpretation of information, lack of knowledge about possible sources of information, or sheer ignorance. It is evidenced by plenty of questions, misinterpretation of information, inaccurate following of instructions, and mythical beliefs infestation (Tanya & Sara, 2011; (Terlecka & Majewski, 2009).
The desired outcomes about this diagnosis include verbalization of patient understanding of the disease processes and potential complications among others. Additionally, the patient is expected to verbalize understanding of the therapeutic conditions and requirements (Tanya & Sara, 2011). The nurses need to perform a stepwise demonstration of procedures and explain to the patients the essence of each step. Patients should also be initiated into the changes that the condition brings along about lifestyle.
Actions/interventions
Information is a critical part of patients’ helping process. Without proper and adequate information, patients may find themselves being re-admitted for cases that could have been avoided. Teaching patients about the disease factors takes various forms (Malini et al., 2008). Firstly, the patients are taken through a review of the surgical process, procedure, and prognosis (Baraza, 2007). Based on this, patients can make informed decisions about their condition.
Additionally, the patient is taken through a demonstration process on incision/dressings as well as drains care and management. Through this, patient independence is enhanced and the risk of exposure to complications is further lowered. The nursing practitioners also recommend to the patients, periodic T-tube collection bag drainage and recoding of the corresponding output for purpose of medical evaluation (Malini et al., 2008; Ibrahim et al., 2008).
This eliminates the risk of reflux, strain, on the tube/appliance seal. Additionally, it avails information on the resolution of ductal edema and appropriate removal duration.
Other than the aforementioned indicatives, much emphasis is placed on diet considerations and more specifically low-fat diets, small meal intakes, and gradual re-introduction of various types of foods with time. This is to eliminate possible discomforts often resulting from improper fats digestions (Litwin & Cahan, 2010). The use of medication is also discussed with patients e.g. use of florantyrone and dehychloric acid among others (Hodgett et al., 2009).
This helps the patients understand the medication process including oral bile replacement which facilitates absorption of fats into the body system. Additionally, patients are informed of the risk of using alcoholic beverages during the healing period and this minimizes the risk of pancreatic involvement in the process (Litwin & Cahan, 2010; Ghazal et al., 2009). Patients are also informed of some occurrences which may surprise them, for instance, loose stools.
This psychological prepares the patients. Additionally, patients are advised to note and avoid foodstuffs that aggravate their conditions to avoid conditions of discomfort. Additionally, the patients are informed about conditions that may necessitate informing of a healthcare worker to avoid condition deterioration (Tanya & Sara, 2011).
Activity limitations are reviewed to provide the patients with limits within which he/they may engage themselves without putting themselves at risk of injury. Generally, information dissemination allows patients to fully understand what the disease entails and what is expected of them if the conditions are to be controlled and their health perfectly regained.
Conclusion
In conclusion, it is important to mention that each of the possible diagnoses must be accompanied by relevant evidence of existence. This is only possible if relevant tests, observations, and evaluations are constantly conducted on the patient. Results from these diagnoses provide the basis upon which decisions regarding the future medical approach of the patient are directed.
The approach borrows a lot from the concept of evidence-practice where every diagnosis is to be based on factual information about the patient. Patient medical history is fundamental to this approach as its dictates the viability of a given diagnosis or not. It is important to note that all measures put priority on the patient well being. Information emerges as a fundamental aspect of diagnosis which determines whether or not a patient’s condition improves upon discharge from the hospital.
References
Andrew, A. G. (2009).Totally Transumbilical Laparoscopic Cholecystectomy. Journal of Gastrointestinal Surgery, 13(3), pp. 533-534.
Baraza, R. (2007). Laparoscopic cholecystectomy at the Nairobi Hospital: a personal experience with 42 cases. East Afr Med J., 82(9), pp. 473-6.
Candela, G. (2007). Minilaparotomy versus laparoscopy in the treatment of cholelithiasis: our experience.G Chir., 28(1-2), pp.35-8.
Ghazal, A. H. et al. (2009). Single-step treatment of gall bladder and bile duct stones: a combined endoscopic-laparoscopic technique. Int J Surg. 7(4), pp. 338-46.
Guerriero, O. (2008). et al. Laparoscopic surgery for acute cholecystitis in the elderly. Our experience. Chir Ital., 60(2), pp.189-97.
Hodgett, S. E. et al. (2009). Laparoendoscopic single site (LESS) cholecystectomy. J Gastrointest Surg., 13(2),pp.188-92.
Hong, T. H. &, You, Y. K. (2009). Transumbilical single-port laparoscopic cholecystectomy : scarless cholecystectomy. Surg Endosc., pp. 1393-7.
Ibrahim, S. et al. (2006). Risk factors for conversion to open surgery in patients undergoing laparoscopic cholecystectomy. World J Surg., 30(9), pp.1698-704.
Ibrahim, S. et al. (2008). Analysis of a structured training programme in laparoscopic cholecystectomy. Langenbecks Arch Surg. 393(6), pp. 943-8.
Jacques, M. et al. (2007). Report of Transluminal Cholecystectomy in a Human Being. Arch Surg., 142(9), pp.823-826.
Ji, W. (2006). Role of laparoscopic subtotal cholecystectomy in the treatment of complicated cholecystitis. Hepatobiliary Pancreat Dis Int., 5(4), pp. 584-9.
Joris, J. Et al. (2007). Pain after laparoscopic cholecystectomy: characteristics and effect of intraperitoneal bupivacaine. Anesth Analg, 81, pp. 379–384
Litwin, D & Cahan, N. (2010). Laparoscopic Cholecystectomy. Surgical Clinics of North America, 88(6), pp.1295-1313.
Lukovich, P., Vanca, T. & Gero, D. (2009). The development of laparoscopic technology in light of cholecystectomies performed between 1994 and 2007. Orv Hetil., 150(48), pp. 2189-93.
Malini, R. C. et al. (2008). Microflora of bile aspirates in patients with acute cholecystitis With or without choleliathiasis: a tropical experience. Brazilian Journal of Infectious Diseases, 12 (3), pp. 483_494.
Miguel, A. C., Frits, B. & Alexander, A. F.(2009).The “invisible cholecystectomy”: A transumbilical laparoscopic operation without a scar. Surgical Endoscopy, 23 (40), pp.896-899.
Pardo-Mindan, F. et al. (2008).Eosinophil inflammatory reaction in isolated organs. Allergol Immunopathol, 8, pp. 23-30.
Ros, A. & Carlsson, P. (2009).Non-randomised patients in a cholecystectomy trial: characteristics, procedures, and outcomes. BMC Surg., 26 (6), pp.17.
Syrakos, T. (2007).Small-incision (mini-laparotomy) versus laparoscopic cholecystectomy: a retrospective study in a university hospital. Langenbecks Arch Surg., 389(3):pp. 172-7.
Tacchino, N., Greco, F. & Matera, D. (2010). Single-incision laparoscopic cholecystectomy: surgery without a visible scar. Gastroenterology Research, 3(5), pp.213-231.
Tajima, K. & Katagiri, T. (2009). Deposits of eosinophil granule proteins in eosinophilic cholecystitis and eosinophilic colitis associated with hypereosinophilic syndrome. Dig Dis Sci, 41(4), 282-288.
Tan, J. T. et al. (2006). Prospective audit of laparoscopic cholecystectomy experience at a secondary referral centre in South australia. ANZ J Surg., 76(5), pp. 335-8.
Tanya, A. R. & Sara O. V. (2011). Cholecystitis and Cholelithiasis Associated with an Intramural Fasciitis-Like Proliferation and Osseous Metaplasia. Pediatric and Developmental Pathology, 14 (1), pp. 80-83.
Terlecka J. & Majewski, W. D. (2009). An investigation of the quality of life of female patients operated by laparoscopic or open way for uncomplicated cholecystolithiasis. Ann Acad Med Stetin, 53(1), pp. 43-52.
Tian, Y. et al. (2009). Laparoscopic subtotal cholecystectomy as an alternative procedure designed to prevent bile duct injury: experience of a hospital in northern China. Surg Today, 39(6):510-3.
Vagenas, K. et al. (2006). Mini-laparotomy cholecystectomy versus laparoscopic cholecystectomy: which way to go? Surg Laparosc Endosc Percutan Tech., 16(5), pp. 321-4.
Witzke, D. B. & Gagliardi, R. J. (2007). Laparoscopic surgery: surgical education in the People’s Republic of China: changes after 15 years. Surg Laparosc Endosc Percutan Tech., 17(3), pp.153-5.
Zhi, Y. W. et al. (2007). Prevention of Biliary Duct Injury in Laparoscopic Cholecystectomy Using Optical Fiber Illumination in Common Bile Duct. Surgical Endoscopy, 22(5), pp. 1211-1213.