1. Focus on Disorders of the Biliary Tract (Relates to Chapter 44, “Nursing Management: Liver, Pancreas, and Biliary Tract Problems” in the textbook) Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

2. 2 Gallbladder Disease CholelithiasisCholelithiasis  Most common disorder of biliary system  Stones in the gallbladder CholecystitisCholecystitis  Inflammation of the gallbladder  Usually associated with cholelithiasis Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

3. 3 Gallbladder With Gallstones Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Fig. 44-16. Cholesterol gallstones in a gallbladder that was removed.

4. 4 X-ray of Gallstones Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Fig. 44-17. X-ray of a gallbladder with gallstones.

5. 5 Gallbladder Disease Common health problem in United StatesCommon health problem in United States 8% to 10% of adults have cholelithiasis.8% to 10% of adults have cholelithiasis. Incidence of cholelithiasisIncidence of cholelithiasis  Higher in women, multiparous women, and persons over 40 years  Estrogen therapy ↑ risk Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

6. 6 Gallbladder Disease Other risk factorsOther risk factors  Sedentary lifestyle  Familial tendency  Obesity More common in whites than in Asian and African AmericansMore common in whites than in Asian and African Americans ↑ incidence in Navajo and Pima ↑ incidence in Navajo and Pima Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

7. 7 Etiology and Pathophysiology CholecystitisCholecystitis  Most commonly associated with obstruction Gallstones or biliary sludgeGallstones or biliary sludge  In absence of obstruction Occurs in older adults and those who have trauma, extensive burns, or recent surgeryOccurs in older adults and those who have trauma, extensive burns, or recent surgery Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

8. 8 Etiology and Pathophysiology Cholecystitis causesCholecystitis causes  Bacteria Escherichia coli—Most commonEscherichia coli—Most common  Other factors include AdhesionsAdhesions NeoplasmsNeoplasms AnesthesiaAnesthesia OpioidsOpioids Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

9. 9 Etiology and Pathophysiology Cholecystitis (cont’d)Cholecystitis (cont’d)  Inflammation Major pathophysiologic conditionMajor pathophysiologic condition Confined to mucous lining or entire wallConfined to mucous lining or entire wall Gallbladder is edematous and hyperemic.Gallbladder is edematous and hyperemic. May be distended with bile or pusMay be distended with bile or pus Cystic duct may become occluded.Cystic duct may become occluded. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

10. 10 Etiology and Pathophysiology CholelithiasisCholelithiasis  Cause of gallstones unknown  Develops when balance that keeps cholesterol, bile salts, and calcium in solution is altered Causes include infection and disturbances in metabolism of cholesterol.Causes include infection and disturbances in metabolism of cholesterol. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

11. 11 Etiology and Pathophysiology Cholelithiasis (cont’d)Cholelithiasis (cont’d)  Bile in gallbladder is supersaturated with cholesterol.  Precipitation of cholesterol results. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

12. 12 Etiology and Pathophysiology Cholelithiasis (cont’d)Cholelithiasis (cont’d)  Other components of bile that precipitate into stones include Bile saltsBile salts BilirubinBilirubin CalciumCalcium ProteinProtein Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

13. 13 Etiology and Pathophysiology Cholelithiasis (cont’d)Cholelithiasis (cont’d)  Stones that are primarily cholesterol are the most common.  Immobility, pregnancy, and inflammatory or obstructive lesions of biliary system ↓ bile flow. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

14. 14 Etiology and Pathophysiology Cholelithiasis (cont’d)Cholelithiasis (cont’d)  Stones may remain in gallbladder or may migrate to cystic or common bile duct.  Cause pain as they pass through ducts May lodge in ducts and produce an obstructionMay lodge in ducts and produce an obstruction Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

15. 15 Etiology and Pathophysiology Cholelithiasis (cont’d)Cholelithiasis (cont’d)  If blockage occurs in cystic duct Bile can continue to flow into the duodenum directly from liverBile can continue to flow into the duodenum directly from liver When bile in gallbladder cannot escape stasis, may lead to cholecystitisWhen bile in gallbladder cannot escape stasis, may lead to cholecystitis Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

16. 16 Clinical Manifestations Vary fromVary from  Indigestion  Moderate to severe pain  Fever  Jaundice Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

17. 17 Clinical Manifestations Initial symptoms of acute cholecystitisInitial symptoms of acute cholecystitis  Indigestion  Pain  Tenderness in right upper quadrant Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

18. 18 Clinical Manifestations Acute cholecystitisAcute cholecystitis  Pain may be acute. May be accompanied by nausea, vomiting, restlessness, and diaphoresisMay be accompanied by nausea, vomiting, restlessness, and diaphoresis  Inflammation manifestations LeukocytosisLeukocytosis FeverFever Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

19. 19 Clinical Manifestations Acute cholecystitis (cont’d)Acute cholecystitis (cont’d)  Physical findings Right upper quadrant tendernessRight upper quadrant tenderness Abdominal rigidityAbdominal rigidity Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

20. 20 Clinical Manifestations Chronic cholecystitisChronic cholecystitis  Symptoms History ofHistory of Fat intoleranceFat intolerance DyspepsiaDyspepsia HeartburnHeartburn FlatulenceFlatulence Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

21. 21 Clinical Manifestations CholelithiasisCholelithiasis  May produce severe symptoms or none at all “Silent cholelithiasis”“Silent cholelithiasis”  Severity depends on Presence of obstructionPresence of obstruction Whether or not stones moveWhether or not stones move Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

22. 22 Clinical Manifestations Cholelithiasis (cont’d)Cholelithiasis (cont’d)  Stones lodged in ducts or moving may cause spasm. Can produce severe painCan produce severe pain Termed biliary colic, although more steady than colickyTermed biliary colic, although more steady than colicky Pain could be accompanied by tachycardia, diaphoresis, and prostration.Pain could be accompanied by tachycardia, diaphoresis, and prostration. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

23. 23 Clinical Manifestations Cholelithiasis (cont’d)Cholelithiasis (cont’d)  Pain may last an hour. When it subsides, tenderness in right upper quadrant develops.When it subsides, tenderness in right upper quadrant develops.  Attacks of pain occur 3 to 6 hours after a heavy meal or after lying down. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

24. 24 Clinical Manifestations Cholelithiasis (cont’d)Cholelithiasis (cont’d)  Total obstruction symptoms JaundiceJaundice Dark amber urineDark amber urine Clay-colored stoolsClay-colored stools PruritusPruritus Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

25. 25 Clinical Manifestations Cholelithiasis (cont’d)Cholelithiasis (cont’d)  Total obstruction symptoms (cont’d) Intolerance to fatty foodsIntolerance to fatty foods Bleeding tendenciesBleeding tendencies SteatorrheaSteatorrhea No urobilinogen in urineNo urobilinogen in urine Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

26. 26 Complications CholecystitisCholecystitis  Gangrenous cholecysitis  Subphrenic abscess  Pancreatitis  Cholangitis Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

27. 27 Complications Cholecystitis (cont’d)Cholecystitis (cont’d)  Biliary cirrhosis  Fistulae  Gallbladder rupture Bile peritonitisBile peritonitis Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

28. 28 Complications Cholecystitis (cont’d)Cholecystitis (cont’d)  Most common complications in older patients and those with diabetes Gangrenous cholecystitisGangrenous cholecystitis Bile peritonitisBile peritonitis Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

29. 29 Complications CholelithiasisCholelithiasis  Cholangitis  Biliary cirrhosis  Carcinoma  Peritonitis  Choledocholithiasis Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

30. 30 Diagnostic Studies UltrasoundUltrasound Laboratory testsLaboratory tests  Liver function studies  WBC count  Serum bilirubin  Serum amylase Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

31. 31 Diagnostic Studies ERCPERCP Percutaneous transhepatic cholangiographyPercutaneous transhepatic cholangiography Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

32. 32 Collaborative Care Conservative Therapy CholecystitisCholecystitis  Acute episode focus on Pain controlPain control Antibiotic treatmentAntibiotic treatment Maintenance of fluid and electrolyte balanceMaintenance of fluid and electrolyte balance  Treatment supportive and symptomatic Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

33. 33 Collaborative Care Conservative Therapy Cholecystitis (cont’d)Cholecystitis (cont’d)  Treatment Gastric decompressionGastric decompression If nausea/vomiting is severeIf nausea/vomiting is severe AnticholinergicsAnticholinergics ↓ secretion ↓ secretion Counteract smooth muscle spasmsCounteract smooth muscle spasms Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

34. 34 Collaborative Care Conservative Therapy Cholecystitis (cont’d)Cholecystitis (cont’d)  Treatment (cont’d) NSAIDsNSAIDs Pain managementPain management CholecystostomyCholecystostomy Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

35. 35 Collaborative Care Conservative Therapy CholelithiasisCholelithiasis  Treatment Depends upon stage of diseaseDepends upon stage of disease Bile acids are used to dissolve stones.Bile acids are used to dissolve stones. Gallstones may occur.Gallstones may occur. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

36. 36 Collaborative Care Conservative Therapy CholelithiasisCholelithiasis  Treatment Two nonsurgical approaches for stone removalTwo nonsurgical approaches for stone removal ERCP with sphincterotomyERCP with sphincterotomy Extracorporeal shock-wave lithotripsyExtracorporeal shock-wave lithotripsy Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

37. 37 Collaborative Care Conservative Therapy CholelithiasisCholelithiasis ERCP with sphincterotomyERCP with sphincterotomy Effective in removing common bile duct stonesEffective in removing common bile duct stones Endoscope passed to duodenumEndoscope passed to duodenum Sphincter of Oddi is widened.Sphincter of Oddi is widened. Basket is used to retrieve stone.Basket is used to retrieve stone. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

38. 38 Endoscopic Sphincterotomy Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Fig. 44-18. During endoscopic sphincterotomy, an endoscope is advanced through the mouth and stomach until Its tip sits in the duodenum opposite the common bile duct. Inset, after widening the duct mouth by incising the sphincter muscle, the physician advances a basket attachment into the duct and snags the stone.

39. 39 Collaborative Care Conservative Therapy CholelithiasisCholelithiasis  Extracorporeal shock-wave lithotripsy Used if stone is too large to passUsed if stone is too large to pass Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

40. 40 Collaborative Care Surgical Therapy Cholelithiasis (cont’d)Cholelithiasis (cont’d)  Laparoscopic cholecystectomy Treatment of choiceTreatment of choice Removal of gallbladder through one to four puncture holesRemoval of gallbladder through one to four puncture holes Minimal postoperative painMinimal postoperative pain Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

41. 41 Collaborative Care Surgical Therapy Cholelithiasis (cont’d)Cholelithiasis (cont’d)  Laparoscopic cholecystectomy (cont’d) Discharge on day or next dayDischarge on day or next day Injury to common bile duct is the main complication.Injury to common bile duct is the main complication. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

42. 42

43. 43 Collaborative Care Surgical Therapy Cholelithiasis (cont’d)Cholelithiasis (cont’d)  Open cholecystectomy Removal of gallbladder through right subcostal incisionRemoval of gallbladder through right subcostal incision T-tube inserted into common bile ductT-tube inserted into common bile duct Ensures patency of the ductEnsures patency of the duct Allows excess bile to drainAllows excess bile to drain Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

44. 44 Placement of T-Tube Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Fig. 44-19. Placement of T tube. Dotted lines indicate parts removed.

45. 45 Collaborative Care Transhepatic Biliary Catheter Used preoperatively inUsed preoperatively in  Biliary obstruction  Hepatic dysfunction Used whenUsed when  Inoperable liver, pancreatic or bile duct carcinoma obstructs bile flow  Endoscopic drainage is unsuccessful. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

46. 46 Collaborative Care Transhepatic Biliary Catheter Inserted percutanouslyInserted percutanously Allows for decompression of obstructed extrahepatic bile ductsAllows for decompression of obstructed extrahepatic bile ducts After insertion, catheter is connected to drainage bag.After insertion, catheter is connected to drainage bag. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

47. 47 Collaborative Care Transhepatic Biliary Catheter Skin careSkin care  Catheter insertion site cleaned daily with antiseptic  Observe for bile leakage. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

48. 48 Collaborative Care Drug Therapy Most commonMost common  Analgesics MorphineMorphine NSAIDsNSAIDs  Anticholinergics AtropineAtropine  Fat-soluble vitamins (A, D, E, K)  Bile salts Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

49. 49 Collaborative Care Drug Therapy Cholestyramine (Questran) may be given for pruritus.Cholestyramine (Questran) may be given for pruritus.  Given in powdered form, mixed with milk or juice Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

50. 50 Collaborative Care Nutritional Therapy Diet modificationsDiet modifications  Major Low saturated fat dietLow saturated fat diet High in fiber and calciumHigh in fiber and calcium  Reduced calorie diet if obese  Eat small, more frequent meals. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

51. 51 Collaborative Care Nutritional Therapy Diet modifications (cont’d)Diet modifications (cont’d)  After laparoscopic cholecystectomy Liquids for dayLiquids for day Light meals for several daysLight meals for several days  After incisional cholecystectomy Liquids to bland diet after return of bowel soundsLiquids to bland diet after return of bowel sounds May need to restrict fats for 4 to 6 weeksMay need to restrict fats for 4 to 6 weeks Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

52. 52 Nursing Management Nursing assessmentNursing assessment  Subjective data Past medical historyPast medical history Obesity, infection, cancer, pregnancyObesity, infection, cancer, pregnancy Medication useMedication use Estrogen, oral contraceptivesEstrogen, oral contraceptives Surgical historySurgical history Previous abdominal surgeryPrevious abdominal surgery Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

53. 53 Nursing Management Nursing Assessment Subjective dataSubjective data  Positive family history  Anorexia  Weight loss  Indigestion  Nausea and vomiting Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

54. 54 Nursing Management Nursing Assessment Subjective data (cont’d)Subjective data (cont’d)  Fat intolerance  Clay-colored stools  Dark urine  Pain in right upper quadrant  Pruritus Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

55. 55 Nursing Management Nursing Assessment Objective dataObjective data  Fever  Restlessness  Jaundice  Tachypnea Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

56. 56 Nursing Management Nursing Assessment Objective data (cont’d)Objective data (cont’d)  Tachycardia  Abnormal liver enzymes  Abnormal gallbladder ultrasound Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

57. 57 Nursing Management Nursing Diagnoses Acute painAcute pain Ineffective self-health managementIneffective self-health management Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

58. 58 Nursing Management Planning Overall goalsOverall goals  Relief of pain and discomfort  No complications postoperatively  No recurrent attacks of cholecystitis or cholelithiasis Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

59. 59 Nursing Management Nursing Implementation Health promotionHealth promotion  Recognize predisposing factors in general health screening. Disease more common in Native AmericansDisease more common in Native Americans Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

60. 60 Nursing Management Nursing Implementation Acute interventionAcute intervention  Nursing objectives Relieve painRelieve pain Relieve nausea and vomitingRelieve nausea and vomiting Provide comfort and emotional supportProvide comfort and emotional support Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

61. 61 Nursing Management Nursing Implementation Acute intervention (cont’d)Acute intervention (cont’d)  Nursing objectives (cont’d) Maintaining fluid and electrolyte balance and nutritionMaintaining fluid and electrolyte balance and nutrition Making accurate assessmentsMaking accurate assessments Observing for complicationsObserving for complications Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

62. 62 Nursing Management Nursing Implementation Acute intervention (cont’d)Acute intervention (cont’d)  Assess pain and administer pain medications.  Provide clean bed, comfortable positioning, and oral care. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

63. 63 Nursing Management Nursing Implementation Acute intervention (cont’d)Acute intervention (cont’d)  Nausea and vomiting May need gastric decompressionMay need gastric decompression Oral hygieneOral hygiene Care of naresCare of nares Accurate intake and outputAccurate intake and output AntiemeticsAntiemetics Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

64. 64 Nursing Management Nursing Implementation Acute intervention (cont’d)Acute intervention (cont’d)  Pruritus Relief measuresRelief measures Baking soda or calamine lotionBaking soda or calamine lotion Soft linenSoft linen Control of temperatureControl of temperature Shortening of nailsShortening of nails Teaching patients to scratch with knuckles rather than nailsTeaching patients to scratch with knuckles rather than nails Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

65. 65 Nursing Management Nursing Implementation Acute intervention (cont’d)Acute intervention (cont’d)  Observe for signs of obstruction. JaundiceJaundice Clay-colored stoolsClay-colored stools Dark, foamy urineDark, foamy urine FeverFever ↑ WBC ↑ WBC SteatorrheaSteatorrhea Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

66. 66 Nursing Management Nursing Implementation Acute intervention (cont’d)Acute intervention (cont’d)  Watch for bleeding. Common sites—mucous membranesCommon sites—mucous membranes If presentIf present Small-gauge needles with gentle pressureSmall-gauge needles with gentle pressure Know patient’s prothrombin time.Know patient’s prothrombin time. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

67. 67 Nursing Management Nursing Implementation Acute intervention (cont’d)Acute intervention (cont’d)  Assess for infection. Temperature elevation with chills and jaundice may indicate choledocholithiasis.Temperature elevation with chills and jaundice may indicate choledocholithiasis. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

68. 68 Nursing Management Nursing Implementation Postoperative carePostoperative care  Laparoscopic cholecystectomy Monitoring for complicationsMonitoring for complications Common problemCommon problem Shoulder pain from irritation of phrenic nerve and diaphragm due to retained CO 2Shoulder pain from irritation of phrenic nerve and diaphragm due to retained CO 2 Place patient in Sims’ position.Place patient in Sims’ position. Encourage deep breathing, ambulation.Encourage deep breathing, ambulation. Administer pain medications.Administer pain medications. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

69. 69 Nursing Management Nursing Implementation Postoperative care (cont’d)Postoperative care (cont’d)  Incisional cholecystectomy Maintain adequate ventilation.Maintain adequate ventilation. Prevent respiratory complications.Prevent respiratory complications. Provide general postop nursing care.Provide general postop nursing care. If T-tube present,If T-tube present, Maintain bile drainage.Maintain bile drainage. Observe function and drainage.Observe function and drainage. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

70. 70 Nursing Management Nursing Implementation Ambulatory and home careAmbulatory and home care  Dietary teaching  Fat-soluble vitamin supplements  Instructions to patient regarding observations indicating obstruction  Stress significance of continued health care. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

71. 71 Nursing Management Nursing Implementation Ambulatory and home careAmbulatory and home care  Laparoscopic cholecystectomy Home care instructionsHome care instructions Teaching essentialTeaching essential  Open-incision cholecystectomy Discharged in 2 to 3 daysDischarged in 2 to 3 days No heavy lifting for 4 to 6 weeksNo heavy lifting for 4 to 6 weeks Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

72. 72 Nursing Management Evaluation Expected outcomesExpected outcomes  Appear comfortable and verbalize pain relief  Verbalize knowledge of activity level and dietary restrictions Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

73. 73 Gallbladder Cancer Primary cancer of gallbladder is uncommon.Primary cancer of gallbladder is uncommon. Majority are adenocarcinomas.Majority are adenocarcinomas. Relationship exists between gallbladder cancer and chronic cholecystitis and cholelithiasis.Relationship exists between gallbladder cancer and chronic cholecystitis and cholelithiasis. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

74. 74 Gallbladder Cancer Early symptomsEarly symptoms  Insidious  Similar to those of cholecystitis and cholelithiasis Late symptomsLate symptoms  Usually those of biliary obstruction Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

75. 75 Gallbladder Cancer Diagnosis and stagingDiagnosis and staging  EUS  Transabdominal ultrasound  CT  MRI  MRCP Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

76. 76 Gallbladder Cancer Usually not detected until disease advancedUsually not detected until disease advanced If found early, can be curativeIf found early, can be curative Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

77. 77 Gallbladder Cancer Factors influencing successful surgical outcomesFactors influencing successful surgical outcomes  Depth of cancer invasion  Extent of liver involvement  Presence of venous or lymphatic invasion  Lymph node metastasis Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

78. 78 Gallbladder Cancer If surgery is not an optionIf surgery is not an option  Endoscopic stenting of biliary tree to reduce jaundice Adjuvant therapiesAdjuvant therapies  Radiation therapy  Chemotherapy Poor prognosis overallPoor prognosis overall Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

79. 79 Gallbladder Cancer Nursing managementNursing management  Supportive care NutritionNutrition HydrationHydration Skin careSkin care Pain reliefPain relief Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

80. 80 The surgical treatment of choice for the patient with symptomatic gallbladder disease is a: 1. Cholecystotomy. 2. Choledocholithotomy. 3. Cholecystoduodenostomy. 4. Laparoscopic cholecystectomy. Audience Response Question Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

81. 81 Postoperatively, a patient with an incisional cholecystectomy has a nursing diagnosis of ineffective breathing pattern related to splinted respirations secondary to a high abdominal incision. The nursing intervention that should be implemented first for this patient is to: 1. Assess lung sounds every 2 to 4 hours. 2. Provide analgesics to relieve incisional pain. 3. Assist the patient to cough and deep breathe every hour. 4. Position the patient on the operative side to splint the incision. Audience Response Question Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

82. Case Study Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 82

83. 83 Case Study 35-year-old woman presents to emergency department complaining of acute abdominal pain.35-year-old woman presents to emergency department complaining of acute abdominal pain. She points to pain in the right upper quadrant.She points to pain in the right upper quadrant. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

84. 84 Case Study She describes the pain as 7 out of 10.She describes the pain as 7 out of 10. Lab values show elevated WBCs and bilirubin.Lab values show elevated WBCs and bilirubin. Ultrasound confirms gallstones.Ultrasound confirms gallstones. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

85. 85 Discussion Questions 1.What is her priority of care? 2.What are her treatment options? 3.What can you teach her about avoiding complications or recurrences? Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.