Cholecystitis is an acute or chronic inflammation of the gallbladder, usually associated with gallstone(s) impacted in the cystic duct, causing distension of the gallbladder. Stones (calculi) are made up of cholesterol, calcium bilirubinate, or a mixture caused by changes in the bile composition. Gallstones can develop in the common bile duct, the cystic duct, hepatic duct, small bile duct, and pancreatic duct. Crystals can also form in the submucosa of the gallbladder causing widespread inflammation. Acute cholecystitis with cholelithiasis is usually treated by surgery, although several other treatment methods (fragmentation and dissolution of stones) are now being used.
CARE SETTING
Severe acute attacks may require brief hospitalization on a medical unit. This plan of care deals with the acutely ill, hospitalized patient.
RELATED CONCERNS
Cholecystectomy
Fluid and electrolyte imbalances, see Nursing Plan CD-ROM
Psychosocial aspects of care
Total nutritional support: parenteral/enteral feeding
Patient Assessment Database
ACTIVITY/REST
May report: Fatigue
May exhibit: Restlessness
CIRCULATION
May exhibit: Tachycardia, diaphoresis, lightheadedness
ELIMINATION
May report: Change in color of urine and stools
May exhibit: Abdominal distension
Palpable mass in right upper quadrant (RUQ)
Dark, concentrated urine
Clay-colored stool, steatorrhea
FOOD/FLUID
May report: Anorexia, nausea/vomiting
Intolerance of fatty and “gas-forming” foods; recurrent regurgitation, heartburn, indigestion, flatulence, bloating (dyspepsia)
Belching (eructation)
May exhibit: Obesity; recent weight loss
Normal to hypoactive bowel sounds
PAIN/DISCOMFORT
May report: Severe epigastric and right upper abdominal pain, may radiate to mid-back, right shoulder/scapula, or to front of chest Midepigastric colicky pain associated with eating, especially after meals rich in fats
Pain severe/ongoing, starting suddenly, sometimes at night, and usually peaking in 30 min, often increases with movement
Recurring episodes of similar pain
May exhibit: Rebound tenderness, muscle guarding, or abdominal rigidity when RUQ is palpated; positive Murphy’s sign
RESPIRATION
May exhibit: Increased respiratory rate
Splinted respiration marked by short, shallow breathing
SAFETY
May exhibit: Low-grade fever; high-grade fever and chills (septic complications)
Jaundice, with dry, itching skin (pruritus)
Bleeding tendencies (vitamin K deficiency)
TEACHING/LEARNING
May report: Familial tendency for gallstones
Recent pregnancy/delivery; history of diabetes mellitus (DM), IBD, blood dyscrasias
Discharge plan
DRG projected mean length of inpatient stay: 4.3 days
May require support with dietary changes/weight reduction
Refer to section at end of plan for postdischarge considerations.
DIAGNOSTIC STUDIES
Biliary ultrasound: Reveals calculi, with gallbladder and/or bile duct distension (frequently the initial diagnostic procedure).
Oral cholecystography (OCG): Preferred method of visualizing general appearance and function of gallbladder, including presence of filling defects, structural defects, and/or stone in ducts/biliary tree. Can be done IV (IVC) when nausea/vomiting prevent oral intake, when the gallbladder cannot be visualized during OCG, or when symptoms persist following cholecystectomy. IVC may also be done perioperatively to assess structure and function of ducts, detect remaining stones after lithotripsy or cholecystectomy, and/or to detect surgical complications. Dye can also be injected via T-tube drain postoperatively.
Endoscopic retrograde cholangiopancreatography (ERCP): Visualizes biliary tree by cannulation of the common bile duct through the duodenum.
Percutaneous transhepatic cholangiography (PTC): Fluoroscopic imaging distinguishes between gallbladder disease and cancer of the pancreas (when jaundice is present); supports the diagnosis of obstructive jaundice and reveals calculi in ducts.
Cholecystograms (for chronic cholecystitis): Reveals stones in the biliary system. Note: Contraindicated in acute cholecystitis because patient is too ill to take the dye by mouth.
Nonnuclear CT scan: May reveal gallbladder cysts, dilation of bile ducts, and distinguish between obstructive/nonobstructive jaundice.
Hepatobiliary (HIDA, PIPIDA) scan: May be done to confirm diagnosis of cholecystitis, especially when barium studies are contraindicated. Scan may be combined with cholecystokinin injection to demonstrate abnormal gallbladder ejection.
Abdominal x-ray films (multipositional): Radiopaque (calcified) gallstones present in 10%–15% of cases; calcification of the wall or enlargement of the gallbladder.
Chest x-ray: Rule out respiratory causes of referred pain.
CBC: Moderate leukocytosis (acute).
Serum bilirubin and amylase: Elevated.
Serum liver enzymes—AST; ALT; ALP; LDH: Slight elevation; alkaline phosphatase and 5-nucleotidase are markedly elevated in biliary obstruction.
Prothrombin levels: Reduced when obstruction to the flow of bile into the intestine decreases absorption of vitamin K.
NURSING PRIORITIES
1. Relieve pain and promote rest.
2. Maintain fluid and electrolyte balance.
3. Prevent complications.
4. Provide information about disease process, prognosis, and treatment needs.
DISCHARGE GOALS
1. Pain relieved.
2. Homeostasis achieved.
3. Complications prevented/minimized.
4. Disease process, prognosis, and therapeutic regimen understood.
5. Plan in place to meet needs after discharge
CARE SETTING
Severe acute attacks may require brief hospitalization on a medical unit. This plan of care deals with the acutely ill, hospitalized patient.
RELATED CONCERNS
Cholecystectomy
Fluid and electrolyte imbalances, see Nursing Plan CD-ROM
Psychosocial aspects of care
Total nutritional support: parenteral/enteral feeding
Patient Assessment Database
ACTIVITY/REST
May report: Fatigue
May exhibit: Restlessness
CIRCULATION
May exhibit: Tachycardia, diaphoresis, lightheadedness
ELIMINATION
May report: Change in color of urine and stools
May exhibit: Abdominal distension
Palpable mass in right upper quadrant (RUQ)
Dark, concentrated urine
Clay-colored stool, steatorrhea
FOOD/FLUID
May report: Anorexia, nausea/vomiting
Intolerance of fatty and “gas-forming” foods; recurrent regurgitation, heartburn, indigestion, flatulence, bloating (dyspepsia)
Belching (eructation)
May exhibit: Obesity; recent weight loss
Normal to hypoactive bowel sounds
PAIN/DISCOMFORT
May report: Severe epigastric and right upper abdominal pain, may radiate to mid-back, right shoulder/scapula, or to front of chest Midepigastric colicky pain associated with eating, especially after meals rich in fats
Pain severe/ongoing, starting suddenly, sometimes at night, and usually peaking in 30 min, often increases with movement
Recurring episodes of similar pain
May exhibit: Rebound tenderness, muscle guarding, or abdominal rigidity when RUQ is palpated; positive Murphy’s sign
RESPIRATION
May exhibit: Increased respiratory rate
Splinted respiration marked by short, shallow breathing
SAFETY
May exhibit: Low-grade fever; high-grade fever and chills (septic complications)
Jaundice, with dry, itching skin (pruritus)
Bleeding tendencies (vitamin K deficiency)
TEACHING/LEARNING
May report: Familial tendency for gallstones
Recent pregnancy/delivery; history of diabetes mellitus (DM), IBD, blood dyscrasias
Discharge plan
DRG projected mean length of inpatient stay: 4.3 days
May require support with dietary changes/weight reduction
Refer to section at end of plan for postdischarge considerations.
DIAGNOSTIC STUDIES
Biliary ultrasound: Reveals calculi, with gallbladder and/or bile duct distension (frequently the initial diagnostic procedure).
Oral cholecystography (OCG): Preferred method of visualizing general appearance and function of gallbladder, including presence of filling defects, structural defects, and/or stone in ducts/biliary tree. Can be done IV (IVC) when nausea/vomiting prevent oral intake, when the gallbladder cannot be visualized during OCG, or when symptoms persist following cholecystectomy. IVC may also be done perioperatively to assess structure and function of ducts, detect remaining stones after lithotripsy or cholecystectomy, and/or to detect surgical complications. Dye can also be injected via T-tube drain postoperatively.
Endoscopic retrograde cholangiopancreatography (ERCP): Visualizes biliary tree by cannulation of the common bile duct through the duodenum.
Percutaneous transhepatic cholangiography (PTC): Fluoroscopic imaging distinguishes between gallbladder disease and cancer of the pancreas (when jaundice is present); supports the diagnosis of obstructive jaundice and reveals calculi in ducts.
Cholecystograms (for chronic cholecystitis): Reveals stones in the biliary system. Note: Contraindicated in acute cholecystitis because patient is too ill to take the dye by mouth.
Nonnuclear CT scan: May reveal gallbladder cysts, dilation of bile ducts, and distinguish between obstructive/nonobstructive jaundice.
Hepatobiliary (HIDA, PIPIDA) scan: May be done to confirm diagnosis of cholecystitis, especially when barium studies are contraindicated. Scan may be combined with cholecystokinin injection to demonstrate abnormal gallbladder ejection.
Abdominal x-ray films (multipositional): Radiopaque (calcified) gallstones present in 10%–15% of cases; calcification of the wall or enlargement of the gallbladder.
Chest x-ray: Rule out respiratory causes of referred pain.
CBC: Moderate leukocytosis (acute).
Serum bilirubin and amylase: Elevated.
Serum liver enzymes—AST; ALT; ALP; LDH: Slight elevation; alkaline phosphatase and 5-nucleotidase are markedly elevated in biliary obstruction.
Prothrombin levels: Reduced when obstruction to the flow of bile into the intestine decreases absorption of vitamin K.
NURSING PRIORITIES
1. Relieve pain and promote rest.
2. Maintain fluid and electrolyte balance.
3. Prevent complications.
4. Provide information about disease process, prognosis, and treatment needs.
DISCHARGE GOALS
1. Pain relieved.
2. Homeostasis achieved.
3. Complications prevented/minimized.
4. Disease process, prognosis, and therapeutic regimen understood.
5. Plan in place to meet needs after discharge
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