Nursing management of the surgical client

Preoperative care
Preoperative care of the client facing gallbladder of biliary surgery is the same as that
described in chapter 21. In addition , preparation involves careful monitoring for early
clinical findings that may indicate the onset of complications from infections or obstruction.
For laporoscopic cholecystectomy. Preoperative preparation involves the same measures
taken for other clients going to surgery . they include NPO status after midnight ,
occasionally an enema to reduce colon mass and reduce the chance of incontinence
contaminating the operative field and sometimes an antibotic.
Assessment
Surgical management of cholelithiasis is elective and not perfomed in an emergency situation
unless obstruction has occurred. Consequently, the client is typically knowledgeable about
the procedure the rationale for it . the client should be assessed, however concerning
knowledge of preoperative and postoperative care.
Diagnosis , Planning , Immplementation
Knowledge deficit : the preoperative client will have as a priority nursing diagnosis
knowledge deficit related to surgery and recovery.
Planninng : expected outcomes . the client will indicate an understanding of the procedure ,
as evidenced by ability to verbalize information regarding it , will demonstrate an ability to
carry out coughing , deep-breathing , and leg exercises : and will have knowledge regarding
the immedate postoperative course.
Implemmentation : reinforce information give the client regarding the surgical procedure .
determine the level of understanding and the learning needs of the client and signicant othes .
material should be provided , if available , that can be read or viewed at the clients ownpace .
verbal instruction and a demonstration are necessary to ensure that the client can perform
postoperative exercises ( turning , coughing , deep-breathing and wound splinting ) properly
as well as understand their importance. The client also needs to have some knowledge of
what to expecte postoperatively ( e.g : IV, fluid : T tube placement and draignage if applicable
and pain control and activity . )
Anxiety because of the surgery and associateed stress, a nursing diagnosis appropriate to
these client is anxiety related to the procedure and outcome.
Planning expected outcomes : the clients will express and demonstrate feelings of comfort
and show decreasing manifestation of anxiety is decreasing and ventilating feelings regarding
the surgical procedure and diagnosis.

Immplementation : take routine postoperative vital sign and asess the clients level of anxiety
by listening and observing . reassure the client and acknowledge theat the the unkwon is
frightening the client , such as the diagnostic or prepatory procedurs . allows significans other
to stay with the client as appropriate.

POSTOPERATIVE CARE
Respiratory status is carefully monitored after surgery of the gallbladder or biliary tract
because of the potential for developing etelactasis and pneumonia. Drainage from any biliary
tube needs to be monitored closely, as does drainage from the incision site , for amount ,
character , and color. Cardiovaskuler status is asessed carefully , as are manifestations of
hemorrhage or shock . hemorrhage, although rare may occur if an inflameed gallblader was
adhered to the liver.
Analgesia for pain management is important and should be given on a regular basis to
promote comfort and rest as well as to enhace the indiviuals ability to cough and deepbreathe.
Hydration and fluid balance must be maintained IV until the client is no longer NPO and
recives fluids orally. When the client is allowed oral intake , the amount of fluid and food
should be sufficient and well-balanced enough to maintain renal function (urine output no
less than 50 ml/hr ) and body weight ( minimal loss of weight ) clients are generally allowed
to progress to a regular diet, with fat content as tolerated.
Assessment
It is includes careful monitoring of vital signs , breath and bowel sounds and general level of
responsiveness to check for complications such as hemorrhage , respiratory problems or
infections. In addition, intake is monitored to reflect ranla function and output carefully
measured including wound dramage, vomiting or nasogastric functioning.
The clients incision should be assessed for redness or sweling . the level of pain is monitored
as are location severity. And the effectiveness of any interventions. Folowing a laporoscopic
cholecystectomy a common postoperative pain pattern is referred pain to the shoulder. The
shoulder pain occurs because of the CO2 that was not released or absorbed by the body . CO2
causes iritation of the purenic nerve and diaghragm and may decrease respiratory excursion.
Diagnosis, planning , implementation
Risk for injury. The postoperative client is at risk for the dvelopment of many complications
leading to the collaborative problem. Write the diagnosis risk fo injury related to
posoperative complications of hemorhage , infection , fluid , and electrolyte imbalance ,
pulmonary changes (atelectasis , pneumonia ) urinary retentio , ileus and decreased
gastrointestinal motility .

Planning : expected outcome

The client will receive appropriate assessments and interventions for aerly complications as
evidenced by stable vital signs : normal pulmonary function : normal gastrointestinal
function : laboratory value within normal limits : normal urinary function which returns
within 6-8 hours postoperatevely an intract incision that does not exhibit redness , odor or
purulent drainage and no manifestations of thrombus or embolus.
Immplemetation
Take routine postoperative vital signs and asess for manisfestation of shock . such as cyanosis
, diaphoresis , cold clammy skin , decreased blood pressure , and increased pulse. As vital
signs are checked , check dressings and drainage tubes at the same time for unsual amounts
of bleeding or drainage. If any of the above-mentioned manisfestations or changes occur , be
sure to check vital signs frequently and notify the physician.
The clients should change position at least every 2 hours. While the client is awake for
running, help him or her to cough and deep-breathe. Some hospitals use devices is is helpful
to demonstarte their use prior to surgery.
Auscultate the lung for rales , rhonchi and diminished breath sounds every 4 hours for the
firsst 24 hous and every 8 hours thereafter. If the client had a cholecystectomy , it will be
even more difficult to take deep breaths and cough because of locaation of the incision. Take
extra care to ensure that the client is comfortable enough to breathe normally . Many
physicians and nurses believe that smaller doses of narcotics given more frequently are
beneficial . splinting helps as well.
Measure intake and output every 4 hours or nore frequently is ordered. Assess amounts for
discrepancies. It is not unusual for new postoperative clients to be behind on fluids for the
first few hours , so do not expect output to equal intake intially. Assess the client for edma
along with the lung sounds every 4 hours as another assurance that the clients is tolerating the
fluids that are being in used.
Unless the client is otherwise compromised the acutely ill at the time of surgery has a history
of other health problems such as heart disease or diabetes), laboratory work will probably not
be ordered until the following day. These values should be monitored for indications of fluid
and electrolyte imbalance.
Generally , the client voids within 6 to 8 hours after surgery. Of not assess the bladder for
distention. It is normal for even an otherwise healthy client not be able to void because of the
effects of anesthesia and narcotics. The physician may order the client to be cathererized to
empty to bladder initially . also the client may need an indwelling foley chateter until fully
ambulatory.
Occasionally, following surget on the gallbladder . the client may return with a nasogastric
tube to suction. Check the tube frequently to ensure that it is patent and that placement is
correct for adequate drainage. A plugged or displaced tube not only causes distention .

naushea nad vomiting but may place undue stress on the surgical site. Auscultate bowel
sounds every 8 hours to note return of normal bowel activity . depending on the surgery the
client may or may not be allowed oral intake before bowel sound return.
For the more involved surgical procedure such as a cholecystectomy , clients are usually not
allowed be a normal diet until they have begun to pass flatus a normal sounds are heard. After
the client is allowed to have fluids or food , continue to assess the client for abdominal
distention and normal bowel sounds to ensure the client that the intake is being tolerated ealry
activity also helps the return of intestinal motility , so the client should be ebcouraged to
begin progression of regular activities as soon as possible.
Pain. The client may be prone to problems related to nursing diagnosis pain related to
surgical procedure and incision.
Planning : expectes outcomes: the client will feel relief of pain , as evidenced by resting
comfortably and quetly : blood pressure and heart rate will be within normal limits and the
clien will be able to tolerate postoperative exercises and activities.
Implementation : assess and document the level location and type of pain as well as the
clients response to pain medication.
Altered oral mucous membrane . another appropriate nursing diagnosis for this client is
altered oral mucous membrane related to NPO status , intubation and nasogastric suctioning.
Planning : expected outcomes : the clients will have oral mucosa as eveidenced by an intact ,
moist oral cavity and verablization of a reduction in , or absense of discomfort.
Implementation : offer oral care at every 2 hours while the clients is NPO . this may consist
of rinshing the mouth with water , using moutwash , swabbing with a moist swab , or
assisting the client with brusing teeth.

Acute cholecystitis
Acute cholecysitis refers to acute inflammation of the gallbladder wall. There is an increased
incidence of cholecystitis in cliens who are overweight , especially those with sedentary lifestyles . certain ethinc groups , including chinese , jewish , and italians. Have a higher rate of
the disease.
Etiology and risk factors
Obstruction of cystic duct by a stone is the usual cause of the acute cholecystitis . in 5% to 10
% of clients , however , calculi obstructing the cystic duct are not found at surgery
(acalculous cholecystitis ). In over 50 % of such cases an underlying cause of the
inflammation is not found.
Pathophysiology
Acute calculous cholecystitis , which appears to be caused by obstruction of the cystic duct in
turn causes distention of the gallbladder . subsequenly (1) venous and lymphatoc drainage is
impaired. (2) poliferation of bacteria occurs. (3) localized cellular irritation or inflatration . or
both , take place , and (4) areas of ischemia may dvelop. The inflamed gallblader wall is
edematous and thickened. And may have areas of gangrene or necrosis. Empyema is the term
used to describe the gallblader that contains pus , which is the equivalent of an intra
abdominal abscess and may be associated with severe sepsis. Recurrent episodes of acute
cholecystitis causse fibrosis of the wall of the gallblader.
Complications of unntreated caute cholecystitis are usually associated with septic
complications , or=thers are consequences of ischemia , inflammation , adhesions and
gangrene : perforation , pericholecystitis and fistula.
Aclaculous cholecystitis is far less common than cholecystitis due to gallstones. It apparently
can be trigerred by (1) multiple blood transfusions (2) gram-negative bacterial sepsis or (3)
tissue damage after burns trauma , or extensive surgery . other possible contributing factors
include hyperalimentation. Porongled fasting , hypotension , anesthesia , narcotic analgestic
and mechanical ventilation with positive and expiratory pressure. Clients with diabetes
mellitus and systemic are also prone to this condition.
Clinical manisfestations and diagnostic findings
Inflammation of the gallblader may be acute or chronic. The most common nad reliable
findings on physical examination is tenderness is the right upper quadrantt , epigastrium or
both . although persons with chronic and avute cholecytisis may compalin of the same type of
pain . the distinguishing factor is the severity and persintance of the pain . chronic
cholecystitis may last several days.
Medical management
Clients suspected of having acute cholecystitis may need to be hospitalized and intial
management should include administratioons of antibiotics effective against organisms found

in the bile in approximately 80% of the cases. These organism include both gram-positive and
gram negatives ( aerobs and anaerobes )

Antibiotics that are effective given singly include ampicilin , cephalospotin or

aminoglycosides . a combination of these drugs may be more effective in clients with
diabetes mellitus or with debilitated conditions.
Nursing management of the medical client
The nursing care plan is the same as for medical management of cholelithiasis expext that it
is certain these clients will receive a course of antibiotics . observe the client for the
development of complications , which mmay include increased pain in the right upper
quadrant or jaundice and decreased or absent bowel sounds . for additional information on
nursing management.
Chrnoc cholecystitis
Chronic cholcystitis sometimes arises as a sequela to acute cholecystitis . typically , however
it develops indepently of acute cholecystisi . in addition it is almost always associated with
gallstones . chonic cholecystitis princippaly affects middle-age and older obese women the
female to male-ration is 3 : 1
Asessment data for chronic cholecystitis are similar to those of acute cholecystitis with
certain exceptions . in chronic states (1) the pain is less severe (2) the temperature is not a
high and the (3A) leukocyte count is lower. Vague manisfestations of dyspepsia , fat
intolerance. Heart burn and flatulence accompany chronic cholecystitis .
Diagnosis of chronic cholecystitiis largely depends on ultrasonography . other diagnostic
procedures provide supplementay information. Diagnostic findings include (1) cholelithiasis
(2) gallbalder wall thickenign ( greater than 3 mm) (3) delayed visualization or
nonvisualization of the gallblader on radionuclide scanning . scarring obstruct the cystic duct
and thus account for this delay in visualization or non.
It may be difficult to differentiate chronic cholecystitis from other disorders. Conditions that
produce manifestation similar to the manisfestation of the cholecystitis (acute and chronic )
the diagnostic and chronic
Cobservative interventions include (1 ) a low fat diet (2) weight reduction and (3)
administrations of ahtcholiergics , sedatives and antacids. When medical interventuon is
ineffetive cholesytectomy may be the treatment of choice. About 90% of clients obtain relief
of manisfestion after cholecystetomy . ninety-five percent of the percent of the gallbladders
removed contaian stones.