NURSING PROCESS:THE PATIENT UNDERGOING SURGERY FOR GALLBLADDER DISEASE
The patient who is to undergo surgical treatment of gallbladder disease is often admitted to the hospital or same-day surgery unit on the morning of surgery. Preadmission testing is often com-pleted a week or more before admission; at that time, the nurse instructs the patient about the need to avoid smoking to enhance pulmonary recovery postoperatively and to avoid respiratory complications. It also is important to instruct the patient to avoid the use of aspirin and other agents (over-the-counter medications and herbal remedies) that can alter coagulation and other bio-chemical processes.
Assessment should focus on the patient’s respiratory status. If a traditional surgical approach is planned, the high abdominal in-cision required during surgery may interfere with full respiratory excursion. The nurse notes a history of smoking, previous respi-ratory problems, shallow respirations, a persistent or ineffective cough, and the presence of adventitious breath sounds. Nutri-tional status is evaluated through a dietary history and general ex-amination performed at the time of preadmission testing. The nurse also reviews previously obtained laboratory results to ob-tain information about the patient’s nutritional status.
Based on all the assessment data, the major postoperative nursing diagnoses for the patient undergoing surgery for gallbladder dis-ease may include the following:
• Acute pain and discomfort related to surgical incision
• Impaired gas exchange related to the high abdominal surgi-cal incision (if traditional surgical cholecystectomy is per-formed)
• Impaired skin integrity related to altered biliary drainage after surgical intervention (if a T-tube is inserted because of retained stones in the common bile duct or another drainage device is employed)
• Imbalanced nutrition, less than body requirements, related to inadequate bile secretion
• Deficient knowledge about self-care activities related to in-cision care, dietary modifications (if needed), medications, reportable signs or symptoms (eg, fever, bleeding, vomiting)
Based on assessment data, potential complications may include:
• Gastrointestinal symptoms (may be related to biliary leak)
The goals for the patient include relief of pain, adequate ventila-tion, intact skin and improved biliary drainage, optimal nutri-tional intake, absence of complications, and understanding of self-care routines.
After recovery from anesthesia, the nurse places the patient in the low Fowler’s position. Intravenous fluids may be given, and na-sogastric suction (a nasogastric tube was probably inserted im-mediately before surgery for a nonlaparoscopic procedure) may be instituted to relieve abdominal distention. Water and other fluids are given in about 24 hours, and a soft diet is started when bowel sounds return.
The location of the subcostal incision in nonlaparoscopic gall-bladder surgery is likely to cause the patient to avoid turning and moving, to splint the affected site, and to take shallow breaths to prevent pain. Because full aeration of the lungs and gradually in-creased activity are necessary to prevent postoperative complications, the nurse should administer analgesic agents as prescribed to relieve the pain and to promote well-being in addition to help-ing the patient turn, cough, breathe deeply, and ambulate as in-dicated. Use of a pillow or binder over the incision may reduce pain during these maneuvers.
Patients undergoing biliary tract surgery are especially prone to pulmonary complications, as are all patients with upper abdom-inal incisions. Thus, the nurse reminds patients to take deep breaths and cough every hour to expand the lungs fully and prevent at-electasis. The early and consistent use of incentive spirometry also helps improve respiratory function. Early ambulation prevents pulmonary complications as well as other complications, such as thrombophlebitis. Pulmonary complications are more likely to occur in the elderly and in obese patients.
In patients who have undergone a cholecystostomy or choledo-chostomy, the drainage tubes must be connected immediately to a drainage receptacle. The nurse should fasten tubing to the dress-ings or to the patient’s gown, with enough leeway for the patient to move without dislodging or kinking it. Because a drainage system remains attached when the patient is ambulating, the drainage bag may be placed in a bathrobe pocket or fastened so that it is below the waist or common duct level. If a Penrose drain is used, the nurse changes the dressings as required.
After these surgical procedures, the patient is observed for in-dications of infection, leakage of bile into the peritoneal cavity, and obstruction of bile drainage. If bile is not draining properly, an obstruction is probably causing bile to be forced back into the liver and bloodstream. Because jaundice may result, the nurse should be particularly observant of the color of the sclerae. The nurse should also note and report right upper quadrant abdomi-nal pain, nausea and vomiting, bile drainage around any drainage tube, clay-colored stools, and a change in vital signs.
Bile may continue to drain from the drainage tract in con-siderable quantities for a time, necessitating frequent changes of the outer dressings and protection of the skin from irritation be-cause bile is corrosive to the skin.
To prevent total loss of bile, the physician may want the drainage tube or collection receptacle elevated above the level of the abdomen so that the bile drains externally only if pressure develops in the duct system. Every 24 hours, the nurse measures the bile col-lected and records the amount, color, and character of the drainage. After several days of drainage, the tube may be clamped for an hour before and after each meal to deliver bile to the duodenum to aid in digestion. Within 7 to 14 days, the drainage tube is removed. The patient who goes home with a drainage tube in place requires instruction and reassurance about its function and care of the tube.
In all patients with biliary drainage, the nurse observes the stools daily and notes their color. Specimens of both urine and stool may be sent to the laboratory for examination for bile pig-ments. In this way, it is possible to determine whether the bile pigment is disappearing from the blood and is draining again into the duodenum. Maintaining a careful record of fluid intake and output is important.
The nurse encourages the patient to eat a diet low in fats and high in carbohydrates and proteins immediately after surgery. At the time of hospital discharge, there are usually no special dietary in-structions other than to maintain a nutritious diet and avoid ex-cessive fats. Fat restriction usually is lifted in 4 to 6 weeks when the biliary ducts dilate to accommodate the volume of bile once held by the gallbladder and when the ampulla of Vater again func-tions effectively. After this, when the patient eats fat, adequate bile will be released into the digestive tract to emulsify the fats and allow their digestion. This is in constrast to before surgery, when fats may not be digested completely or adequately, and flatulence may occur. However, one purpose of gallbladder surgery is to allow a normal diet.
Bleeding may occur as a result of inadvertent puncture or nick-ing of a major blood vessel. Postoperatively, the nurse closely mon-itors vital signs and inspects the surgical incisions and drains, if in place, for evidence of bleeding. The nurse also periodically as-sesses the patient for increased tenderness and rigidity of the ab-domen. If these signs and symptoms occur, they are reported to the surgeon. The nurse instructs the patient and family to report to the surgeon any change in the color of stools because this may indicate complications. Gastrointestinal symptoms, although not common, may occur with manipulation of the intestines during surgery.
After laparoscopic cholecystectomy, the nurse assesses the pa-tient for loss of appetite, vomiting, pain, distention of the ab-domen, and temperature elevation. These may indicate infection or disruption of the gastrointestinal tract and should be reported to the surgeon promptly. Because the patient is discharged soon after laparoscopic surgery, the patient and family are instructed verbally and in writing about the importance of reporting these symptoms promptly.
The nurse instructs the patient about the medications that are prescribed (vitamins, anticholinergics, and antispasmodics) and their actions. It also is important to inform the patient and fam-ily about symptoms that should be reported to the physician, in-cluding jaundice, dark urine, pale-colored stools, pruritus, or signs of inflammation and infection, such as pain or fever.
Some patients report one to three bowel movements a day. This is the result of a continual trickle of bile through the chole-dochoduodenal junction after cholecystectomy. Usually, such fre-quency diminishes over a period of a few weeks to several months.
If a patient is discharged from the hospital with a drainage tube still in place, the patient and family may need instructions about its management. The nurse instructs them in proper care of the drainage tube and the importance of reporting to the physician promptly any changes in the amount or characteristics of drainage. Assistance in securing the appropriate dressings will reduce the patient’s anxiety about going home with the drain or tube still in place. (See Chart 40-3 for more details.)
With sufficient support at home, most patients recover quickly from cholecystectomy. However, elderly or frail patients and those who live alone may require a referral for home care. During home visits, the nurse assesses the patient’s physical status, especially wound healing, and progress toward recovery. Assessing the patient for adequacy of pain relief and pulmonary exercises also is impor-tant. If the patient has a drainage system in place, the nurse assesses it for patency and appropriate management by the patient and fam-ily.
Assessing for signs of infection and teaching the patient about the signs and symptoms of infection are also important nursing in-terventions. The patient’s understanding of the therapeutic regimen (medications, gradual return to normal activities) is assessed, and previous teaching is reinforced. The nurse emphasizes the impor-tance of keeping follow-up appointments and reminds the patient and family of the importance of participating in health promotion activities and recommended health screening.
Expected patient outcomes may include:
• Reports decrease in pain
a) Splints abdominal incision to decrease pain
b) Avoids foods that cause pain
c) Uses postoperative analgesia as prescribed
• Demonstrates appropriate respiratory function
a) Achieves full respiratory excursion, with deep inspira-tion and expiration
b) Coughs effectively, using pillow to splint abdominal incision
c) Uses postoperative analgesia as prescribed
d) Exercises as prescribed (eg, turns, ambulates)
• Exhibits normal skin integrity around biliary drainage site (if applicable)
a) Is free of fever, abdominal pain, change in vital signs, or bile, foul-smelling drainage, or pus around drainage tube
b) Demonstrates proper management of drainage tube (if applicable)
c) Identifies signs and symptoms of biliary obstruction to be noted and reported
d) Has serum bilirubin level within normal range
• Obtains relief of dietary intolerance
a) Maintains adequate dietary intake and avoids foods that cause gastrointestinal symptoms
b) Reports decreased or absent nausea, vomiting, diarrhea, flatulence, and abdominal discomfort
• Absence of complications
a) Has normal vital signs (blood pressure, pulse, respira-tory rate and pattern, and temperature)
b) Reports absence of bleeding from gastrointestinal tract, biliary drainage tube/catheter (if present) and no evi-dence of bleeding in stool
c) Reports return of appetite and no evidence of vomiting, abdominal distention, and pain
d) Lists symptoms that should be reported to surgeon promptly and demonstrates an understanding of self-care, including wound care