Angelite Nurses

• Cholecystitis/Cholelithiasis
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• Cholecystectomy/Choledochostomy

1. General information
1. Cholecystectomy: removal of the gallbladder with insertion of a T-tube into the common bile duct if common bile duct exploration is performed
2. Choledochostomy: opening of common duct, removal of stone, and insertion of a T-tube
3. Cholecystectomy performed via laparoscopy for uncomplicated cases when client has not had previous abdominal surgery
2. Nursing interventions: routine preoperative care
3. Nursing interventions: postoperative
1. Provide routine post-op care.
2. Position client in semi-Fowler's or side-lying positions; reposition frequently.
3. Splint incision when turning, coughing, and deep breathing.
4. Maintain/monitor functioning of T-tube.
1. Ensure that T-tube is connected to closed gravity drainage.
2. Avoid kinks, clamping, or pulling of the tube.
3. Measure and record drainage every shift.
4. Expect 300-500 ml bile-colored drainage first 24 hours, then 200 ml/24 hours for 3-4 days.
5. Monitor color of urine and stools (stools will be light colored if bile is flowing through T-tube but normal color should reappear as drainage diminishes).
6. Assess for signs of peritonitis.
7. Assess skin around T-tube; cleanse frequently and keep dry.
5. Provide client teaching and discharge planning concerning
1. Adherence to dietary restrictions
2. Resumption of ADL (avoid heavy lifting for at least 6 weeks; resume sexual activity as desired unless ordered otherwise by physician); clients having laparoscopy cholecystectomy usually resume normal activity within two weeks.
3. Recognition and reporting of signs of complications (fever, jaundice, pain, dark urine, pale stools, pruritus)

Appendicitis

General information

6. Inflammation of the appendix that prevents mucus from passing into the cecum; if untreated, ischemia, gangrene, rupture, and peritonitis occur
7. Most common in school-age children
8. May be caused by mechanical obstruction (fecaliths, intestinal parasites) or anatomic defect; may be related to decreased fiber in the diet
3. Assessment findings
1. Diffuse pain, localizes in lower right quadrant
2. Nausea/vomiting
3. Guarding of abdomen, rebound tenderness, walks stooped over
4. Decreased bowel sounds
5. Fever
6. Diagnostic tests
1. WBC increased
2. Elevated acetone in urine
4. Nursing interventions
1. Administer antibiotics/antipyretics as ordered
2. Prevent perforation of the appendix; do not give enemas or cathartics or use heating pad
3. In addition to routine pre-op care for appendectomy
1. Give support to parents if seeking treatment was delayed.
2. Explain necessity of obtaining lab work prior to surgery.
4. In addition to routine post-op care
1. Monitor NG tube (usually with low suction).
2. Monitor Penrose drains.
3. Position in semi-Fowler's or lying on right side to facilitate drainage.
4. Administer antibiotics as ordered.

1. General information
1. Cholecystitis: acute or chronic inflammation of the gallbladder, most commonly associated with gallstones. Inflammation occurs within the walls of the gallbladder and creates a thickening accompanied by edema. Consequently, there is impaired circulation, ischemia, and eventual necrosis.
2. Cholelithiasis: formation of gallstones, cholesterol stones most common variety
3. Most often occurs in women after age 40, in postmenopausal women on estrogen therapy, in women taking oral contraceptives, and in the obese; Caucasians and Native Americans are also more commonly affected.
4. Stone formation may be caused by genetic defect of bile composition, gallbladder/bile stasis, infection.
5. Acute cholecystitis usually follows stone impaction, adhesions; neoplasms may also be implicated.
2. Medical management
1. Supportive treatment: NPO with NG intubation and IV fluids
2. Diet modification with administration of fat-soluble vitamins
3. Drug therapy
1. Narcotic analgesics (Demerol is drug of choice) for pain. Morphine sulfate is contraindicated because it causes spasms of the sphincter of Oddi.
2. Anticholinergics (atropine) for pain. (Anticholinergics relax smooth muscle and open bile ducts.)
3. Antiemetics
4. Surgery: cholecystectomy / choledochostomy
3. Assessment findings
1. Epigastric or right upper quadrant pain, precipitated by a heavy meal or occurring at night
2. Intolerance for fatty foods (nausea, vomiting, sensation of fullness)
3. Pruritus, easy bruising, jaundice, dark amber urine, steatorrhea
4. Diagnostic tests
1. Direct bilirubin transaminase, alkaline phosphatase, WBC, amylase, lipase: all increased
2. Oral cholecystogram (gallbladder series): positive for gallstone
4. Nursing interventions
1. Administer pain medications as ordered and monitor for effects.
2. Administer IV fluids as ordered.
3. Provide small, frequent meals of modified diet (if oral intake allowed).
4. Provide care to relieve pruritus.
5. Provide care for the client with a cholecystectomy or choledochostomy.